Introduction: Baroness Carr  of Walton-on-the-Hill

The right honourable Dame Sue Lascelles Carr, DBE, having been created Baroness Carr of Walton-on-the-Hill, of Walton-on-the-Hill in the County of Surrey, was introduced and took the oath, supported by Lord Thomas of Cwmgiedd and Lord Burnett of Maldon, and signed an undertaking to abide by the Code of Conduct.

Battery and Hydrogen-powered Aircraft
 - Question

Baroness Scott of Needham Market: To ask His Majesty’s Government what progress they have made towards achieving their aspiration to have battery and hydrogen-powered aircraft connecting different parts of the United Kingdom.

Lord Davies of Gower: My Lords, zero-emission flight is one measure in the Government’s jet zero strategy to deliver net-zero UK aviation by 2050. The development of hydrogen and battery electric aircraft is technically challenging, and the Government are supporting the necessary innovation in the UK to overcome these barriers. Between 2013 and 2030, industry and government will invest over £5 billion to develop transformational aircraft technology and will continue to collaborate closely to drive progress through the Jet Zero Council.

Baroness Scott of Needham Market: I thank the Minister for that reply. Are the Government giving any consideration to using public service obligation flights as a test bed for these new technologies, given that they are essential services that are also short and domestic?

Lord Davies of Gower: The DfT has published a jet zero strategy setting out the Government’s approach to delivering net-zero UK aviation by 2050. The strategy anticipates that a range of measures, including sustainable aviation fuels, zero-emission flights, carbon market measures and greater efficiencies in aircraft, airports and airspace will be require in tandem to achieve net zero by 2050.

Baroness Boycott: My Lords, does the Minister believe that the principle of the polluter pays should apply to aviation, as it does across much of government policy, so that the cost of the emissions trading scheme, as well as the guaranteed prices for producers of sustainable fuels and the cost of an SAF mandate,  should be paid by the airlines and, in turn, by the consumers who take the flights? This will not make flights exorbitantly expensive; it will ensure that the people who benefit from such transport bear the costs of it.

Lord Davies of Gower: I thank the noble Baroness for that question. In fairness to the airlines, a number of industry projects within the UK seek to bring hydrogen-propelled aircraft, for example, into commercial service. Airbus has its ZEROe project, through which it intends to bring into commercial service the world’s first zero-emission commercial aircraft by 2035. Launched in 2022, its ZEROe demonstrator project will explore how hydrogen propulsion technology can be configured, and there are many other projects within the industry.

Lord Kamall: My Lords, although hydrogen can be a green fuel, it is important that we focus more on green hydrogen, which is created by electrolysis using renewable energy, rather than blue or grey hydrogen. Can my noble friend tell us about the emphasis on green hydrogen as opposed to other hydrogens in order to meet the net-zero targets?

Lord Davies of Gower: The UK Hydrogen Capability Network Phase 0 Project is a 12-month study funded by the Department for Business and Trade and led by the Aerospace Technology Institute, which builds on the ATI’s FlyZero study key recommendations. It will define the operating model for a group of open-access facilities designed to accelerate the development of liquid hydrogen propulsion aircraft technologies, capabilities and skills in the UK.

Lord Foulkes of Cumnock: My Lords, would not this development have lots of incidental advantages? For example, it would make it easier for Peers from all parts of the United Kingdom to get down to Westminster, thus ending the outrage that over half the Members of a House that purports to represent the whole of the United Kingdom are from the south-east of England.

Lord Davies of Gower: I am grateful for the noble Lord’s wisdom, and, as someone who travels from Wales, I appreciate his comments.

Baroness Randerson: My Lords, the Government’s Jet Zero strategy set a target for domestic flights to reach net zero by 2040, but instead there has been a big increase in internal flights taken by private planes and helicopters, and many of those journeys could have been made more quickly by train. Can the Minister tell us what the Government are doing to discourage the use of private internal flights? Perhaps he can also have a word with his right honourable friend the Prime Minister to suggest that he might favour other forms of transport rather than private jets and helicopters.

Lord Davies of Gower: There are security issues for the Prime Minister, which I am sure the noble Baroness will appreciate. It is still a free world and people can choose how they want to travel, and   we must remember that although we are anti-emissions, we are not anti-flying. We must reduce emissions from aviation while retaining our ability to fly.

Lord Watts: My Lords, may I suggest to the Minister that we build a high-speed rail connection to Manchester and then on to Sheffield, which might reduce the number of flights that are needed?

Lord Davies of Gower: A very popular suggestion from the noble Lord, and his point is made.

Baroness Goldie: My Lords, to help the noble Lord, Lord Foulkes, in the attainment of his admirable objectives, can my noble friend the Minister confirm to what extent his department is liaising with the Ministry of Defence, which, through the RAF and Project Monet, is making excellent progress in the pursuit of sustainable fuels?

Lord Davies of Gower: My noble friend is absolutely right. Civil aviation and the Royal Air Force are making combined efforts to reduce emissions with technology.

Lord Tunnicliffe: My Lords, the Hydrogen in Aviation alliance has indicated that Britain is well placed to become a global hydrogen aviation leader, stimulating the economy and providing 100,000 jobs. The alliance announced that this would require a 10-year funding commitment. History shows that the level of continuity required to achieve an entirely new fuel requires state funding as part of any alliance. How much real government money is being put into this project?

Lord Davies of Gower: The Department for Business and Trade supports research and development in UK aerospace manufacturing through the Aerospace Technology Institute. It is a competitive process through which industry can access match funding from government to develop technologies. The programme is set to run until at least 2030, and as part of the advanced manufacturing plan announcement on 17 November, His Majesty’s Treasury confirmed that £975 million of government funding will be provided as part of a £4.5 billion total package for manufacturing between 2025 and 2030. That is in addition to the £685 million from the Government between 2022 and 2025.

Lord Fox: My Lords, my noble friend made a very good point that I do not think was fully covered by the Minister, regarding the ideal nature of battery-powered planes for internal domestic flights. For that to happen, we need not just the planes but the infrastructure in the airport. What plans are there in the jet zero strategy to ensure that all domestic airports have the infrastructure, such as power and charging facilities, to make this happen?

Lord Davies of Gower: First, the use of battery electric has been proven in small, manned aircraft. However, the weight, plus lack of power density of batteries currently on the market, limits the range and payload of electric aircraft. To support adoption of  new aircraft such as hydrogen and battery-powered, the Government have supported research into airport preparedness for handling aircraft through £4.2 million of funding for the zero-emission flight infrastructure project. The findings will be published in March.

Lord Ranger of Northwood: My Lords, the House might be getting used to my personal interest in electric mobility, and I want to build on the point made by the noble Lord, Lord Fox, about landing pads. I am aware of two major international organisations that are progressing and quite advanced in their development of electric aeroplanes to be used for personal mobility—as in air taxis—to help people travel easily and in a sustainable way. It is not airports they are looking for, it is landing pads, which will be less invasive in our environment. Is that something we are looking into? I know that across Europe, sites are being searched for landing areas to be trialled in the testing of these planes.

Lord Davies of Gower: My noble friend makes a very interesting point. I do not have the information in front of me, but I will certainly look at that and write to him.

Child Labour and Artisanal Cobalt Mining in the DRC
 - Question

Lord Alton of Liverpool: To ask His Majesty’s Government what action they are taking to support international efforts to end the use of child labour from artisanal cobalt mining in the Democratic Republic of the Congo and to exclude cobalt from this source from the global supply chain.

Lord Benyon: My Lords, the use of child labour in the Democratic Republic of the Congo remains concerning. We regularly raise the issue of child labour in DRC’s artisanal cobalt mining sector both with the DRC Government and through multilateral fora such as the Human Rights Council.

Lord Alton of Liverpool: My Lords, I thank the Minister for that reply. Will he initiate an urgent investigation into reports of children standing knee-deep with their bare skin in toxic pools mining for cobalt, study the research of Professor Siddharth Kara published in Cobalt Red and challenge the absurdity of companies relying on assurances from state-run Chinese companies in the Congo that human rights norms are met? Under the terms of the Modern Slavery Act, will he consider, for offences committed within supply chains, making offending companies subject to company disqualification, as with GDPR violations, and meet me and other noble Lords who are concerned about these issues to discuss kite-marking and how products can be labelled in a way that demonstrates they come from places  where slave labour and child labour is being used, so consumers can make up their own mind about whether they want to be complicit in buying such products?

Lord Benyon: I would be happy to meet the noble Lord, and perhaps he could bring with him people who could help us to move forward. We are a world leader in this. We passed the Modern Slavery Act. We now have requirements on companies with a turnover greater than £36 million to define their supply chains very accurately to make sure that the awful images the noble Lord describes have no part in the supply of cobalt. The Democratic Republic of the Congo has 70% of the world’s cobalt. We want to make sure that it comes to the world market in a way that is complicit with the standards we require.

Lord Collins of Highbury: My Lords, can I just pick up on the last point made by the noble Lord, Lord Alton, and by the Minister? The fact is that the Modern Slavery Act provides for those companies to make a statement, but that is it. There is no other requirement—no mechanism for enforcement where there is a breach. This is a really serious matter, not only in the DRC but in other countries where we are importing goods made by slaves and children. Will the Government act? There has been criticism of this for many years, since the first debate on the Act, so will we act to make sure compliance is compulsory?

Lord Benyon: Following a public consultation, the Government committed to taking forward an ambitious package of measures to strengthen the Modern Slavery Act’s transparency legislation, including extending reporting requirements to public bodies with a budget of £36 million or more, mandating the specific reporting of topic statements and what they must cover, requiring organisations to publish a modern slavery statement on the online registry and introducing financial penalties for organisations that fail to publish annual statements. This requires primary legislation, but in time we want to see it on the statute book.

Lord Howell of Guildford: My Lords, is not one means of reducing our cobalt reliance on dangerous and thoroughly undesirable resources to work on the Washington agreement we have made on critical minerals, which has been agreed between the two Governments, whereby, if we dig out more cobalt in this country—apparently we have some—and use it in our motor cars or use American cobalt, we will get a 15% subsidy on all cars sold into the American market? Can the Minister tell us how that is getting on?

Lord Benyon: I am grateful to my noble friend. He will understand that my relative newness in this role means that my learning curve is steep. I will do some research and discuss it with him when we next meet.

Lord Purvis of Tweed: My Lords, when I was in Lubumbashi in September, I saw for myself the extent of the Chinese concessions for cobalt mining. With regard to east DRC, in June I raised in the Chamber a report from the US State Department that singled out Rwanda’s human rights record with its  support of the M23 group, which, as it said, has committed multiple violations of international humanitarian law and human rights abuses. There is concern that the FCDO has been silent while it is discussing a migration agreement with Rwanda. Can the Minister allay those concerns at the Dispatch Box today and condemn Rwanda’s human rights record in this regard?

Lord Benyon: I can absolutely reassure the noble Lord. We regularly raise the conflict in eastern DRC with the Governments of DRC, Rwanda and elsewhere in the region. We judge doing this privately to have more impact. In these conversations, we urge all parties to deliver on their commitments agreed through the Nairobi and Luanda processes. This includes the withdrawal of armed groups, including M23, and the ceasing of all external support to armed groups operating in the DRC.

Baroness Butler-Sloss: My Lords, I declare my interest as co-chairman of the All-Party Parliamentary Group on modern slavery and the vice-chairman of the Human Trafficking Foundation. Have the Government looked at the way in which the Americans deal with supply chains, by having hot goods that are not entitled to enter the country? If they have not looked at that, would they do so?

Lord Benyon: I will certainly take that back. I thank the noble and learned Baroness for her work in this area. It is vital that we are able to define accurately and have complete transparency through supply chains. As a previous questioner identified, cobalt is vital for technologies that we want to see that will help lower emissions, and it is used in a whole variety of daily products. We must make sure that it is not mined using child labour or slavery and that we are requiring companies to be transparent in their supply chains.

Lord Wigley: My Lords, may I press the Minister further on that point regarding the specific steps that the Government are now taking to identify whether cobalt-containing products imported into the UK are produced by child labour in the DRC?

Lord Benyon: Through our modern slavery legislation and through the work we are doing in a variety of multilateral fora, we are trying to make sure that, with international companies mining not just cobalt but a whole range of other things—for diamonds, for example, using the Kimberley process, or for conflict minerals—we are doing work in-country, leading on partnerships that have seen great benefit, with children going into school as opposed to working in mines. UK taxpayers’ money is doing that, and we are working really hard on this. We want to make sure that companies are playing their part, too, and that their supply chains are transparent.

Lord Harris of Haringey: The Minister has asserted that we are a world leader in modern slavery work. That may have been the case, but can he explain, then, why there was such a hiatus between the departure of the previous modern slavery commissioner and the appointment of a new one? I believe that the new one  has not yet taken up her post. Secondly, if we are to lead on these issues, what are we doing to make sure that we are more resilient in terms of minerals such as cobalt?

Lord Benyon: On the first point, I will write to the noble Lord about the appointment of the new commissioner. On the second point, there is a market imperative to use less of certain products because they are expensive to obtain and transport across the world, so there is a market mechanism. But there is also a driver for the Government through innovation, particularly in areas such as battery manufacture, to reduce both the weight of batteries and, therefore, the quantity of minerals such as cobalt that are used. The Government are providing funding for innovation in a whole range of ways.

Lord Bellingham: My Lords, further to the question from the noble Lord, Lord Purvis, I have also had the chance to visit most parts of the DRC and have seen for myself the scourge of child labour. The Minister mentioned that we must get these children out of mines, where they are being persecuted and exploited, and into schools and education. Can he tell us what we are doing to tilt our aid in that direction? Does he have any figures on these children going into school?

Lord Benyon: The UK’s Partnership Against Child Exploitation programme, which ended in September, was a consortium of six partners that worked to combat the worst forms of child labour in the Central African Republic, Ethiopia and the Democratic Republic of the Congo; the United Kingdom was a key supporter of that partnership. The programme delivered key achievements: 8,430 children are going back to school following a consortium intervention, while 2,583 children have completed training in rights and skills because of PACE support. The point from the noble Lord, Lord Alton, is absolutely right—there is still a serious problem—but we are having some success and we want to see more of it.

Lord Stirrup: My Lords, this Question highlights an important part of a much wider issue. Can the Minister say what progress the Government have made towards developing a strategic plan to ensure the supply of crucial resources in the round in order to enhance national security and resilience while, at the same time, supporting the values that we rightly espouse?

Lord Benyon: This is a massive issue, and I thank the noble and gallant Lord for raising it. The integrated review refresh looked at this. We must make sure that our economy can get what it needs in order to provide for our own needs and so that we can benefit the rest of the world. We cannot look at the security of this nation without looking at supply chains. With a country such as the Democratic Republic of the Congo, as I said, having 70% of the world’s cobalt, which is a mineral that we need, we want to be at the forefront of making sure both that we have high-integrity supply chains for such minerals and that they are integrated into our whole security policy.

English Flood Defences
 - Question

Earl Russell: To ask His Majesty’s Government, following widespread flood damage caused by both storm Babet and Ciarán, what action they are taking to ensure all English flood defences are fit for purpose.

Lord Benyon: My Lords, the Government are working closely with the Environment Agency and other relevant authorities to ensure that flood defences impacted by recent flooding are repaired. Following Storm Babet and Storm Ciarán, more than 14,000 inspections of flood protection assets have been conducted, with action taken wherever performance was compromised. We have allocated more than £200 million a year for the maintenance of flood defences and aim to achieve getting 94% to 95% of flood-risk assets to their target condition.

Earl Russell: My Lords, extreme weather is now the new normal. When it comes to flood events, I am not certain that we are ready for the future. Although I recognise that the Government have doubled capital funding, information from the National Audit Office just two weeks ago revealed that the number of properties to be protected from flooding by 2027 has been cut by 40%. In addition, Unearthed has shown that 40,000 of England’s vital flood defences are so damaged as to be almost useless. Why are there no longer-term plans or concrete targets for flood defences beyond 2026-27? Is it time for a full review of our flood defences?

Lord Benyon: We constantly look over the horizon to make sure that we factor in important phenomena such as climate change and the extreme weather events we are seeing. The National Audit Office has reduced that figure principally because of the inflationary effect on the cost of building concrete and steel defences. Of course, that is only part of it; nature-based solutions are now becoming a key part of our defences. I really question the Unearthed data. The Environment Agency puts all defences in a category from 1 to 5. If it is a category 4, meaning that it is not where you want it to be, it still functions in the main. When we know that a flood is coming, a minor change can be made. That was an unfair description by Unearthed; the figure of 94% to 95% of our assets being in good condition is worthy of comment.

Bishop of St Albans: My Lords, more than half of Britain’s best farmland is on flood plains. Farmers are providing a public service by protecting towns and cities from flooding, but this means that they incur costs. What are His Majesty’s Government doing to ensure that farmers are adequately recompensed for this public service that they provide for our nation?

Lord Benyon: The right reverend Prelate is correct. Farmers can enter into some agri-environment schemes, which, as we know, are now targeted on  public goods. One of those is protecting the public from flooding so, if farmers are holding flood-water on their land, they should be rewarded for it. They can also access the farming recovery fund, which provides assistance to farmers whose agricultural land has been damaged by flooding and declared a natural disaster by the Government. We provide financial assistance up to 100%, with a minimum grant level of £500 and a maximum of £25,000; that has been accessed in some extreme flooding conditions.

Earl of Kinnoull: My Lords, thousands of homes are eligible for protection in the UK under the Flood Re protection scheme, which is an insurance scheme. With these two serious storms, can the Minister tell us a bit about how the scheme has performed during this period and whether there are any plans both to look at the scheme again and to examine, in particular, the eligibility criteria and rating levels within it?

Lord Benyon: I was involved in the setting up of Flood Re more than a decade ago. It has undoubtedly brought peace of mind to a huge number of households that could not get flood insurance or could get it only for an exorbitant amount. It needs looking at every so often, as building costs and our understanding of flood risk increase. The Government are working with the Flood Re in a variety of ways to ensure that we are making it fit not for just today but, as I said earlier, recognising that we could soon see houses we did not previously think were a flood risk become a flood risk. We want to make sure that this scheme covers them too.

Baroness McIntosh of Pickering: My Lords, for Flood Re to work effectively, surely there should be no building on functional flood plains. Does my noble friend the Minister agree that there is a vital role for maintenance and recognise the work of the drainage authorities? I have the honour of being the vice-president of the Association of Drainage Authorities. Will he also ensure that, where the Environment Agency fails to do the work, farmers and others can do it through the drainage boards and maintain these flood-banks?

Lord Benyon: This is going to come as a shock to my noble friend but I am not going to agree with her first point. If we say that we will not build on flood plains, that means no new houses in Leeds, London and many of our other major cities. What matters is not whether you build on flood plains but how you build. I was in the Netherlands last week, hearing about houses that are actually flood defences. There is so much successful building on flood plains around the world. There are also some fantastic examples in this country from the last 50 years of how not to do it. I urge caution when saying that we should not build on flood plains. We have increased the funding for maintenance of defences by £22 million per year, and are supporting farmers and others in their work to keep our homes from flooding.

Baroness Hayman of Ullock: My Lords, despite the Government doubling their capital funding in England to combat flooding, we know that a quarter of new flood defence projects will not be going ahead.  The Environment Agency has blamed inflation for these cuts, as the Minister acknowledged earlier. A shortfall in the agency’s finances means that it cannot keep flood protections to the required condition to protect homes. Due to this inflation, the EA is now £34 million short of its expected budget. How will the Government make up this shortfall?

Lord Benyon: As the noble Baroness says, we have put record amounts into flood protection through the Environment Agency—£5.2 billion from 2021-27, which is a doubling of the investment. Additionally, there is an extra £200 million on maintenance, a £22 million increase in the maintenance fund this year and the Environment Agency is conducting a review, expecting around 69,200 high-consequence assets, of which 63,700 are at the required condition. We are not complacent. We recognise that there is an increased threat from flooding, as there is from a variety of extreme weather conditions. We have made this a priority for government and will continue to support the Environment Agency with what it needs to keep our homes safe from flooding.

Baroness Walmsley: My Lords, I will follow on the Minister’s answer to the question from the noble Baroness, Lady McIntosh of Pickering. Given that we already have houses built on flood plains and that there will probably be more, what are the Government doing to mandate resilient design—he hinted that other countries have done that—and to retrofit houses that have already been built there? Things can be done, such as laying concrete flooring and raising the level of the electricity circuits. Will the Government ensure that this sort of design is built in when it becomes necessary to build new houses on flood plains?

Lord Benyon: I totally agree. Through our conversations on housing design and the incentives and financial support that we give to householders to retrofit, we are seeing those householders protect their houses themselves. In flood-risk areas, where you put the plug sockets can make a difference if a house floods, so recovery funding must also drive that. We must listen to the Environment Agency when it says that developments should not take place, but if the developer, working with the local authority, and the Environment Agency, says that these mitigation measures have been put in place, we will copy what goes on in places such as the Mississippi basin and the Netherlands, where there is intelligent building in flood-risk areas.

Earl of Clancarty: My Lords, are the Government satisfied that the public are sufficiently aware of flood risk when they buy a house, aside from what needs to be done legally in terms of a flood-risk report?

Lord Benyon: Ultimately, it is the responsibility of the purchaser of a house to look at all the risks. There comes a point where government cannot be involved in every transaction and action of a human life. However, it is key that data on flood risk, of which there can now be an enormous amount, is accessible through the Environment Agency’s website and through local authorities. That should be accessed by people buying a house and those advising them.

Residential Leasehold for Flats
 - Question

Lord Kennedy of Southwark: To ask His Majesty’s Government what plans they have to abolish residential leasehold for flats.

Baroness Taylor of Stevenage: My Lords, on behalf of my noble friend Lord Kennedy and with his permission, I beg leave to ask the Question standing in his name on the Order Paper.

Baroness Penn: My Lords, I declare my interest as a leaseholder.
The Government are extending the benefits of freehold ownership to more home owners. Reforms in the Leasehold and Freehold Reform Bill will help leaseholders to buy their freeholds and will end the sale of new leasehold houses so that, other than in exceptional circumstances, all new houses will be freehold from the outset. For flats, the Government remain committed to reinvigorating commonhold to give developers and home owners a viable alternative to leasehold should they choose it.

Baroness Taylor of Stevenage: My Lords, I thank the Minister for her Answer. Of course, we welcome the reform of leasehold, but with 5 million leasehold properties in England, 70% of which are flats, there is disappointment that they are not included in the Bill. Also, it does not appear that the Bill bans the sale of leasehold houses, either. The Times is reporting that the Minister’s department did not have time to include the leasehold ban before the Bill was introduced this week. Can she please clarify whether it is the Government’s clear intention to ban leasehold? If so, when will we see the relevant clauses?

Baroness Penn: My Lords, I can reassure noble Lords that it is the Government’s intention to bring forward clauses to ban the sale of new leasehold houses within this Bill. We intend to bring forward those clauses during the Commons stages. When it comes to flats, on the other hand, reform is more complicated. They have shared fabric and infrastructure and therefore require some form of arrangement to facilitate management. This has traditionally been facilitated by a lease. Therefore, banning leasehold flats is inherently more complicated. We will be taking forward, at a later date, reforms to the commonhold system to allow that to replace the leasehold system.

Lord Lisvane: Does the absence of these clauses lead the Minister to draw a conclusion which has general application—that Parliament is asked to consider far too much legislation, to be proceeded with at far too great a pace?

Baroness Penn: I do not draw that conclusion. Leasehold reform is complex. We have consulted widely and are taking time to get things right. I understand   the desirability of bringing forward these clauses as soon as possible for Parliament’s scrutiny and that is what the Government intend to do.

Lord Young of Cookham: My Lords, I very much welcome the provisions of the leasehold Bill, which provide a better balance between the interests of freeholders and leaseholders. However, the Bill does not do what Michael Gove said it would. He said:
“I don’t believe leasehold is fair in any way. It is an outdated feudal system that needs to go. And we need to move to a better system and to liberate people from it”.
He wanted to replace leasehold with commonhold, but the Bill does not even mention commonhold. So will my noble friend be surprised if some of us seek to amend the Bill to deliver what her Secretary of State actually wants?

Baroness Penn: My Lords, I have tried to learn not to be surprised by any amendments tabled to government Bills by your Lordships’ House, but I would like to reassure my noble friend that this Bill is focused on helping leaseholders now by making existing leases fairer and more affordable. We have focused on legislating where we can make a genuine improvement to leaseholders’ daily lives right away. For example, we are making it cheaper and easier for leaseholders to purchase the freehold of their building or a 999-year lease on their property and take control of their building’s management from the freeholder. When it comes to reforms to commonhold, we continue to consider the Law Commission’s report in detail to find the best way forward and we are committed to taking forward that additional work.

Lord Goddard of Stockport: My Lords, one of the most expensive consequences of being a leaseholder, especially in flats, is the service charges that freeholders can level against you. They are completely unregulated and can be totally exorbitant. Does the Minister agree that we need to abolish service charges, especially for flats, and replace them with a commonhold system, which would be much fairer for leaseholders and would stop unscrupulous freeholders from ripping off hard-working families?

Baroness Penn: I can reassure the noble Lord that the Bill does contain provisions to bring greater transparency around how service charges are brought for leaseholders, so that there is greater accountability for what those charges go to and leaseholders have a greater ability to challenge them if they think they are unfair.

Baroness Fox of Buckley: My Lords, as the Minister will know, the most frustrating thing for those of us who are leaseholders is the lack of control. There is a tried and tested formula for residents’ control, which is recognised in the Bill, and that is freehold. At the very least, will the Government consider a really simple, cost-free change to the Bill, which would be a mandated share of freehold for all new flats? That would at least prove that they are really committed to tackling the issue of getting rid of toxic leasehold for ever.

Baroness Penn: My Lords, as I have said, we believe that commonhold provides a potential way forward to move away from leasehold for flats, but there is reform of commonhold that needs to take place so that it will be fit for purpose. I reassure the noble Baroness, as I have others, that there are significant measures in this Bill that do exactly what she pointed towards, which is giving leaseholders greater control over the properties that they own and live in.

Lord Adonis: My Lords, the wider problem, of course, is that there are far too few new homes, either leasehold or freehold. Is the noble Baroness aware that France, with a population of about the same size as ours, now has 12 million more homes than Britain, and has built more than twice as many new homes as we have over the last 13 years? There has been a net addition of 2 million homes, a high proportion for social lease. I know that Ministers are not talking to their European counterparts at the moment, but does she not think that learning something from our European partners could be valuable in tackling the housing crisis?

Baroness Penn: My Lords, the Government are absolutely committed to increasing supply. The noble Lord is right that that is part of the solution, particularly when we have in place the provisions to ban new leaseholds in new houses. But the Government are delivering on that promise. We are on track to deliver our commitment to 1 million new homes during this Parliament. We are investing £10 billion in increasing the supply of homes, and in the last few years we have seen some of the highest rates of home delivery in decades.

Lord Cormack: My Lords, will my noble friend convey to Mr Gove the most generous offer made by the noble Lord, Lord Young of Cookham, on behalf of the House, which was apparent from the reaction to his question? Why does she not tell him that this House can put right what he has not yet got right?

Baroness Penn: I am sure that this House will communicate its views to the department as we progress the Bill throughout the scrutiny. It will go through the Commons first and I look forward to debating the provisions in detail when it reaches the Lords.

Lord Shipley: My Lords, commonhold is used widely across the world, so why has it taken the Government so long to consider what works so successfully across the rest of the world?

Baroness Penn: My Lords, this Bill, and the other reforms that we have made in this space, are comprehensive and complex. We have taken time to look, consult and bring forward the proposals that will have the biggest impact on leaseholders today, while also committing to ongoing reform in the future.

Lord Jackson of Peterborough: My Lords, the Autumn Statement contained a commitment to take forward reforms to residential estate investment trusts. Will my noble friend take forward the support the  House has for leveraging significant private sector funding into much-needed residential accommodation via REITs?

Baroness Penn: Yes, the Autumn Statement set out the way forward we are going to take on that issue. We need proper financing to support our ambitions for more homebuilding. Some of that comes through government support, but the private sector is a key partner here and we need to do everything that we can to unlock investment.

Lord Kamall: My noble friend mentioned there were complications in extending freehold to leaseholders in flats. She does not have to answer everything right now, but I wonder whether she could write to me, and deposit a copy in the Library, about some of those complications, so noble Lords can better understand those barriers to extending freehold?

Baroness Penn: I would be very happy to write to my noble friend but, as I said, in looking at the distinction between houses and flats, the majority of houses have always been provided as freehold, and there are few justifications for building leasehold houses. We have seen, in recent years, this practice being exploited by developers to levy unfair charges on home owners. Flats, on the other hand, have shared fabric and infrastructure and therefore require some form of arrangement to facilitate management. Traditionally, this has been facilitated by a lease, but, as we discussed, commonhold is an alternative way to do this.

Ecocide Bill [HL]
 - First Reading

A Bill to introduce the crime of ecocide; and for connected purposes.

Baroness Boycott: My Lords, I declare my interest as vice-chair of Peers for the Planet.
The Bill was introduced by Baroness Boycott, read a first time and ordered to be printed.

Protection of Care Recipients and Carers Bill [HL]
 - First Reading

A Bill to make provision for the protection of care recipients and their carers; and for connected purposes.
The Bill was introduced by Lord Hunt of Kings Heath, read a first time and ordered to be printed.

National Health Service: 75th Anniversary
 - Motion to Take Note

Lord Hunt of Kings Heath: Moved by Lord Hunt of Kings Heath
That this House takes note of the 75th anniversary of the National Health Service and its performance in waiting times.

Lord Hunt of Kings Heath: My Lords, I refer the House to my membership of the GMC council. I was privileged to lead a debate 25 years ago in your Lordships’ House to celebrate the 50th anniversary of the NHS. My noble friends Lord Brooke and Lady Pitkeathley spoke in that debate, and I am delighted that they are speaking today—they are great survivors.
In 1997, the Labour Government inherited an NHS in crisis, with low morale and long waiting times. I was privileged as a Minister to contribute to a complete revival of the service’s fortunes. I pay tribute to my colleagues, to the right reverend Prelate the Bishop of London, who played a pivotal role as Chief Nursing Officer, and to my noble friend Lord Prentis, who took up the post of general secretary of UNISON at a very important time in the turnaround in the service’s fortunes.
The NHS plan of 2000 was a programme of huge vision: 100 new hospitals built; major investment in the workforce and an agenda for change; new services such as NHS Direct and walk-in centres; maximum 18-week waits for elective treatments; maximum four-hour waits for A&E; patients were actually able to see their GP. In 2010, the British Social Attitudes survey showed satisfaction with the NHS at over 70%, the highest rate it has ever recorded. Today, satisfaction has plummeted to 29%—the lowest figure ever recorded. The main reasons for this dramatic drop are waiting times for GPs and hospitals, staff shortages and lack of government spending.
How did the coalition and then the Conservative Governments throw away such a brilliant inheritance? The evidence is very clear: austerity was to blame, based on a small-state ideology and introduced just as the economy was recovering to a 2.2% growth rate in 2010. Growth was killed off by the coalition Government, who devastated public investment. The huge social cost of this self-imposed harm is plain to see. By 2020, poverty in working families had reached a record high. Life expectancy increases stalled for the first time in this country in 100 years. In 1952, the UK had the seventh-highest life expectancy at birth in the world. OECD data shows that, by 2020, it had fallen to 36th.
Austerity targeted local government the worst. It had a huge impact on adult social care and, today, has left half a million people waiting just for an assessment, let alone any support. We now have the prospect of the Home Office wanting to restrict care workers coming from abroad by increasing the salary requirement and restricting dependants. The obvious solution—to pay care staff more—is not viable because, as Juliet Samuel wrote in the Times this morning, the same Government are the care sector’s main customer and will not pay up. You could not make it up.
The NHS has been through the longest financial squeeze in its history. Its annual growth from 1948 to 2019-20 was 3.6%, but under the coalition Government dropped to a miserly 1.1%. Any increased funding that came post Covid has been eroded in real terms due to high inflation, resulting in a very stretched NHS. It is no wonder waiting lists are now a record 7.8 million people. In 2022-23, only 56% of those attending A&E were admitted, transferred or discharged within four hours, compared to 98% in 2010.
What has the Government’s response been to all this? First, we had the costly disaster of the Health and Social Care Act 2102, which enforced a wasteful market on all clinical services, disrupted collaboration and the integration of services, and cost millions of pounds. Earlier this week, the Minister was here bringing in a regulation to get rid of the whole wretched thing. We also had a former Prime Minister’s pledge on 40 new hospitals, which was exposed as a deceit early on. Even the current Prime Minister some time ago, in one of his many pledges, promised to cut NHS waiting lists, but that has been downgraded because NHS leaders have been told to prioritise controlling costs. Up and down the country, the NHS is stopping schemes to cut waiting times because it cannot get the funds; for instance, for new equipment to increase productivity.
The NHS has faced two major periods of crisis in its history. The first was in the early 1990s and the second is now. The common cause is a long period of Conservative government. We fixed it last time and we can do it again, but it will be tough. As Paul Johnson from the IFS commented after the Autumn Statement,
“a combination of high spending on debt interest, low growth, and the demands of an ageing population mean that there is little scope to increase spending on hard-pressed public services … growth is the only way out of this”.
But this Government’s dismal performance offers little hope of that. Interest rates are set to remain high according to the Governor of the Bank of England who, two days ago, said that the UK economy’s potential to grow is
“lower than it has been in much of my working life”.
How do we go forward from here? We need a Government who will drive through a huge modernisation programme. Inescapably, funding will have to keep pace with demography and technical advances, but we also clearly need to get the most out of every pound we spend.
Data from the Office for National Statistics reveals that more working-age people are self-reporting long-term health conditions, with 36% saying that they have at least one. The case for investing health resources to get those people back to work is convincing and ought to appeal to the Treasury. Wes Streeting has suggested that we also need cultural change which gives local services much greater freedom to reform and to try new and different ways of providing healthcare while embracing the latest technology. This is really important: productivity will not be improved by beating a big stick so, please, we do not need any restructuring, crony contracts, wasted payments on management consultants, rip-off outsourcing or agency bills—all characteristic of the current Government’s approach.
The NHS needs to plan with multiyear revenue settlements, and it needs investment in capital. We are years behind other countries in investing in capital. The result, as the NHS Confederation reported this week, is a less productive service, still hampered by
“Victorian estates, too few diagnostic machines and outdated IT systems”.
We need system reform. Primary care is overstretched, with too many patients ending up inappropriately in A&E. Planned treatments get cancelled as a result. Patients’ conditions deteriorate and hospitals then find it difficult to discharge them, owing to pressures  on adult social and community care. Add in mental health demands and it is no wonder the system is falling over, but we need a whole-system solution to deal with that problem.
Ministers are fond of talking about integration but, for patients, the experience of seamless care between primary, secondary, tertiary and social care is a distant dream. We also need to take advantage of our fantastic science base, and our pharma and medical technology sectors. The problem is that investment in R&D and clinical trials has dipped. We must get that back and ensure that the NHS adopts the innovations being made in this country to get the advantage to patients and improve productivity. This is key to what we have to do in the future.
Our workforce is all important. The Institute for Government was absolutely right in arguing that an improved approach to setting pay, workforce planning and enhancing working conditions would help to reset the relationship with our staff and start to resolve recruitment and retention problems. We will have to pay particular attention to the lowest-paid staff and try to align social care staff more to NHS terms and conditions.
We know that there is a huge demand for healthcare professionals globally. It is very unlikely that countries’ demands will totally be met, so we have to look at the smart use of AI and technology to liberate clinicians from the clunky and frustrating IT systems found littered across the NHS.
We need a stronger preventative process to reduce health inequalities and improve life expectancy. We need social care to be given a fundamental boost. Do your Lordships remember that Prime Minister Johnson promised to fix social care? That went well. As a minimum, every vulnerable person should expect an assessment and some form of care and support. In the long term, we have to end the lottery of care which leaves many people who are above the means-tested level none the less struggling hugely to pay care home fees.
Primary care also needs a reset. I commend Sir John Oldham who, under the last Labour Government, did fantastic work in helping GPs to improve their effectiveness. Primary care has to become a place again where GPs want to work and where if patients want direct access to their GP, they can get it.
There must be no delay in bringing legislation to reform the Mental Health Act 1983. The failure of the Government to bring the Bill before us because it is not a measure that would show a gap between them and us is deplorable. That Bill has consensus support and was produced by an expert. We know the way forward, but it has been delayed yet again. I commend a report, A Mentally Healthier Nation, which was recently signed by dozens of organisations with an interest in mental health. It sets out a fantastic programme for better prevention, quality and support.
Finally, I will mention the people who I represented for a lot of my earlier life, when I did proper jobs—NHS managers and leaders. If we are serious about an improvement agenda, can we stop disparaging those people? Can we stop false economies by restricting the number we invest in and start to invest properly in their training, support and development? Amanda  Pritchard, the chief executive of NHS England, gave evidence to the Health and Social Care Select Committee only a couple of weeks ago in which she talked about the patchiness of giving those crucial people the kind of support they need to do the jobs that need to be done.
I am grateful to so many noble Lords for taking part in our debate. I am convinced that, with drive and determination, we can turn the NHS around. Wes Streeting has described his reform programme as having three aims: hospital to community, analogue to digital, and sickness to prevention. They sound about right to me. Despite the Government’s dismal record, austerity funding and attacks from the right, the NHS’s founding principles—being comprehensive, free at the point of use and tax-funded—remain in place.
In ending, I think it is appropriate to give the last word to Nye Bevan, founder of the NHS. He said:
“The NHS will last as long as there’s folk with faith left to fight for it”.
There are plenty of people prepared to do that. I beg to move.

Lord Lexden: My Lords, following the splendid introductory speech by the noble Lord, Lord Hunt, which ended with a quotation from Nye Bevan, I will make a little historical contribution to this important debate, if I may. Other speakers will be dealing with the present and looking forward to the future; I hope a historian may be forgiven for looking back to the origins of the NHS, the 75th anniversary of which we are celebrating.
Cinemagoers in the 1940s learned much about public affairs from the widely admired Pathé News, which was shown before the main film. In March 1944, audiences who saw that month’s Pathé News heard the following words from the Minister of Health about the formation of a National Health Service:
“Whatever your income, if you want to use this service—nobody is going to try to make you unless you want to—there will be no charge for treatment. The National Health Service will include family doctors who you choose for yourselves and who will attend you in your own homes when this is necessary”.
The clipped, kindly, authoritative voice continued:
“It will cover any medicines you may need, specialist advice and, of course, hospital treatment, whatever the illness, special care for mothers and children and a lot of other things besides. In fact, every kind of advice and treatment you may need … We are out to improve the health of every family and the whole nation. If we cut out the money worries which illness brings, then there would be no reason to put off getting advice and treatment”.
That is how the nation heard that it could look forward to the provision of comprehensive health services, free at the point of use, from which it was to benefit so profoundly in the years that lay ahead.
The voice from which it heard about these radical reform plans was that of Sir Henry Willink, the Conservative Health Minister in Churchill’s wartime coalition. It fell to Willink to work out how to achieve this promised transformation of healthcare in Britain. He set about the task in a spirit of consensus, telling Pathé News viewers:
“It is not a cut and dried scheme. These proposals are for discussion in Parliament, and we want them talked about by everyone concerned, and you, everyone in this audience, are very much concerned”.
The nearer the scheme came to fruition, the more concerned the British Medical Association grew about the effect it would have on their members’ private practice. Willink made a number of concessions to the BMA, agreeing that doctors would not, as had originally been envisaged, be grouped as salaried employees into health centres under local authority control. This concession had far-reaching results, which the Labour Party had to accept when it found itself in charge of the legislation that created the NHS after 1945.
Today, Sir Henry Willink is almost entirely forgotten, his contribution to building our National Health Service unsung. Willink was a calm, modest, intellectual figure, later master of a Cambridge college, who had no taste for rough party politics, totally unlike the brilliant, flamboyant, combative Nye Bevan, who denounced the Tories as “lower than vermin” when the NHS was officially launched in July 1948. By the way, younger elements in the Conservative Party responded by forming Vermin Clubs, with little membership badges featuring ugly creatures. Miss Margaret Roberts, later Mrs Margaret Thatcher, had quite a collection of these badges.
Since Bevan carried the legislation through Parliament, it would be absurd to question his central role. But neither he nor the Labour Party deserve to monopolise the credit for the building of the NHS. Bevan’s biographer, Dr John Campbell, refers to
“the long and cumulative process by which the Service came into existence in 1948 … There can be no doubt that some form of National Health Service would have come into being after 1945 whoever had won the General Election”.
The Tories, who made a firm commitment to finish Willink’s work in their 1945 manifesto, made a cardinal political error as Bevan’s great NHS Bill was going through the Commons: Willink moved a hostile amendment, opposing the nationalisation of all hospitals, voluntary and municipal. This enabled Labour, in the rough and tumble of party politics, to portray the Conservatives as opposed in principle to the NHS, which was of course totally untrue.
Perhaps on the 75th anniversary of the NHS this year, it might be appropriate to remember Henry Willink as well as Nye Bevan. Willink stood for consensus; Bevan for conflict. Could it be that, over the last 75 years, the NHS would have benefited from a little more of Willink’s consensus and a little less of Bevan’s party strife? Would progress have been easier to achieve if politicians of all parties had worked together, in full partnership with health professionals, in that spirit of national unity, embodied in Churchill’s wartime coalition, from which our NHS emanates?
I will make just one point about the provision of health services today. I do so with sadness, disappointment and a little anger. In the debate on the King’s Speech, alongside the noble Baroness, Lady Donaghy, I drew the attention of the House to the compelling case that the Royal Osteoporosis Society, supported by parliamentarians of all parties, had made for government funding of fracture liaison services. A commitment appeared to have been given in this House in a ministerial reply to a debate on these services in September. It contained the following words:
“We are proposing to announce, in the forthcoming Autumn Statement, a package of prioritised measures to expand the provision of fracture liaison services and improve their current quality”.—[Official Report, 14/9/23; col. GC 241.]
The Autumn Statement last week contained no such announcement. Commenting on the U-turn, my noble friend Lord Black of Brentwood, who introduced September’s debate but cannot be in his place today, deplored the Government’s unwillingness to make what is, in reality, a tiny investment of some £27 million per annum in fracture liaison services. This callous decision will blight the lives of tens of thousands of people with pain and disability and put many people at risk of premature death. This was a deplorable position indeed in the year of the 75th anniversary of our NHS.

Baroness Walmsley: My Lords, I congratulate the noble Lord, Lord Hunt of Kings Heath, on his excellent introductory speech. He hit all the nails very firmly on the head.
As the NHS reaches its 75th year, it is a very different and much larger beast than when it started out. The challenges are not just greater but different. On the upside, to a great extent we have conquered infectious diseases through vaccination and sanitation. Because of the success of medical science, our population is ageing, leading to greater demand for healthcare. On the other hand, we have a high level of health inequality and poverty, and a food system that does not provide a healthy diet for many people. Preventable diseases are now the greatest cause of illness and death. In 1948, people walked everywhere; many did manual labour, so obesity was rare; they ate seasonally and cooked their meals at home, and ultra-processed foods did not exist. But the air was not necessarily cleaner, because we burned coal to heat our homes. Today, we lead a very different life.
So, post-Covid, the NHS has five major challenges. There is the state of social care, causing too many people to enter hospital and stay there for too long. Linked to that, there is a crisis in ambulance service response times and A&E waiting times, causing excess deaths and harm. Many diseases, including cancer, are being diagnosed far later than they could be, leading to poor outcomes. Long waiting lists for urgent and elective care are leading to damage to the economy as people cannot work while they wait. There is too little preventive work to help people lead healthier lives.
The Government’s response is a focus on increasing the front-line workforce while ignoring the poor communication and system planning in the service. While we certainly need to train and retain more health professionals, especially in deprived areas, they are not the only people the workforce plan should be focusing on. We need system planners and communications experts. The money available for the NHS to tackle these problems is not infinite, which means we need greater productivity.
Nobel laureate Paul Krugman said:
“Productivity isn’t everything, but in the long run, it is almost everything”.
A crude definition of productivity is the ratio of inputs to outputs. Some think this is all about individuals working harder, but NHS staff are all already working  extremely hard. It is not about working harder but working smarter. It is about improving outcomes. It is also not just about national initiatives. There is bound to be poor buy-in for national initiatives when staff on the ground often have a better idea of what could be done better. That is not to say there is no room for national initiatives, but they do not need to be designed by McKinsey.
There are problems with measuring real productivity in the NHS: how to adjust for the mix and quality of outputs and recognising the difference between outputs and outcomes. The NHS produces a wide variety of outputs. GP appointments are not the same as hip replacements, but the service has quite sophisticated statistical ways of dealing with this. It is harder to adjust for quality. Doing two knee replacements rather than one looks productive, but not if the second was needed only because the first was botched; and especially, as in the case of a lady I know, if the patient has to see the consultant three times before he will accept that there is something wrong. Then we must ask, is the outcome better as a result of the NHS having done something? The lesson here is that it is productive to listen to patients. Unfortunately, the NHS has cut back on patient-reported outcome measures, which are a valuable way to assess outcomes. My first question to the Minister is: are there plans to reinstate or replace PROMs?
A recent internal paper about productivity said that NHSE is
“very good at generating ideas”
for efficiency initiatives but does not have clear processes to evaluate them. It added:
“The overall volume of initiatives means it is very likely that the system is overwhelmed, which means that initiatives are not as effective as they could be. Moreover, a lot of the initiatives we are taking forward lack the buy-in from front-line staff that is needed to make changes stick”.
The system and infrastructures that support waiting list management include IT and tools for proactive patient tracking, as well as the processes that staff follow to efficiently and accurately co-ordinate pathways for patients on waiting lists. Millions of hours of clinicians’ time are wasted due to inadequate IT systems. A recent BMA report found that four in five doctors believe that improving IT infrastructure and digital technology would help to tackle backlogs. Can the Minister therefore say whether systems analysts and IT and AI specialists are included in the workforce plan, as well as medical professionals? We did not just win the Battle of Britain using pilots.
Sadly, there are too many examples of the skills of our health professionals being wasted because of inefficient systems planning and poor communications. A recent example concerns former BBC journalist Rory Cellan-Jones, who suffered a broken elbow and facial bruising following a fall. He spent two unnecessary days in hospital and calculated that 90% of the staff time spent on his case could have been avoided with better planning and communications. It was eight days after his accident before he received appropriate treatment. It was not just a question of communication between staff, but communication with him. He says in his blog:
“Getting information about one’s treatment seems like an obstacle race where the system is always one step ahead. … But communication between medical staff within and between hospitals also appears hopelessly inadequate, with the gulf between doctors and nurses particularly acute. I also sense that, in some cases, new computer systems are slowing not speeding information through the system. On Saturday morning, as we waited in the surgical assessment unit, four nurses gathered around a computer screen while a fifth explained … all the steps needed to check-in a patient and get them into a bed. It took about 20 minutes and appeared to be akin to mastering some complex video game”.
It also took four hours to get the paperwork for his discharge.
My Lords, I have experienced a similar situation and it grieves me to see our skilled professionals not being used in the most cost-effective way. What are the Government planning to do about this?

Baroness Taylor of Bolton: My Lords, I congratulate my noble friend Lord Hunt on securing this debate and on outlining not just current problems but potential ways forward, which is what we should be concentrating on. This is an important debate, because few issues are more significant for us as individuals and indeed as society. Our individual and collective health and well-being very much depend upon a robust NHS. The figures my noble friend gave, including the 7.8 million on the waiting list, showed very clearly that we do not have that today, I am afraid.
Time is always limited in these debates, and there are certainly many aspects of the current state of the NHS that warrant mentioning—alas, far too many to mention. However, unusually, I want to start by mentioning some of the briefings we have probably all received in the last few days since this debate was announced. I was particularly struck by the briefing paper from the Association of Directors of Adult Social Services. It highlighted that in August, more than 470,000 people were waiting for a care and support assessment to begin, up 8% on March of this year. It highlighted the almost universal view that increased pressures on the NHS will put even more pressure on adult social care—a significant and growing problem.
We also had an interesting paper from a well-known opticians, pointing out that greater use of the glaucoma referral system, with optometrists working with the NHS, can significantly benefit patients and the whole of the NHS service; a similar situation arises with audiology services. The Royal College of Psychiatrists told us in its detailed paper about the contribution that early support hubs can make. The Bowel Cancer UK group gave us striking figures that nine in 10 people will survive bowel cancer if diagnosed early, but only four out of 10 are actually being diagnosed early. The most significant point about all these examples is that they highlight issues that are not simply about asking for more funds. They are pointing out and giving examples of how early invention can not only benefit patients and individuals but reduce long-term costs.
All of those examples and that theme link up with what we were told by Universities UK, which has outlined the problems we are seeing with applications from students for positions in critical areas of nursing and the whole range of medical specialties. Even if we did get the increase in the number of students, we are  also short of clinical academics and people to do the teaching to get the placements they need in our hospitals. This area is particularly critical to the way forward. Although the Government sometimes boast about increasing student numbers, there is still a very long way to go before we recover from the cuts made from 2010. That is one of the reasons why we are in such a serious situation.
I want also to mention one other issue that particularly alarms me. In October, just a month ago, the Care Quality Commission rated 65% of maternity services in England as inadequate or requiring improvement. Its report says, having inspected 73% of all maternity units:
“The overarching picture is one of a service and staff under huge pressure”.
Despite the efforts of staff, who are often praised because of their efforts by people on the receiving end, many women are still not receiving the safe, high-quality care they deserve. The CQC went on to say that this was particularly a problem for ethnic-minority women, for whom the service was particularly poor. Its overall assessment was that we have a deteriorating position in maternity services. All of us who have children know that the moment a child is born is one of the most important times of your life. It really is alarming that, in 2023, 75 years after the establishment of the health service, which was partly formed to improve maternity services, we have that situation.
I must just mention a related issue from my local area. Last week, it was reported that no babies have been born in Kirklees for around 18 months. Kirklees is one of the largest metropolitan council areas, covering Huddersfield, Dewsbury, Batley and lots of other smaller towns, yet there are no facilities for childbirth there. The units in Huddersfield and Dewsbury have been closed. Just imagine being a pregnant woman going into childbirth and having to travel potentially for an hour in those circumstances. The reason given is staffing issues. There are plans for the future, but in some cases it will take nearly two years before that service becomes available.
I have the figures for the increasing number of doctors, midwives and consultants under a Labour Government, but I end by echoing what my noble friend said: we fixed it last time; we are going to have to fix it again.

Baroness Pitkeathley: My Lords, I too thank my noble friend Lord Hunt for introducing this debate in his typically tub-thumping and inspiring manner.
I owe my life to the NHS—quite literally. Without the NHS’s resources and the commitment and skill of those who work in it, I would not be standing here making yet another speech on health in your Lordships’ House to join the many I have made since I became a Member at same time as my noble friend. It is no exaggeration to say that it causes me emotional distress to hear the phrases that people are now using about our beloved NHS—“The NHS is not what it was”, or, “You can’t rely on the NHS now”—or to see friends in my village spending their life savings on paying for  surgery in the private sector because they are no longer able to tolerate the pain in their knee, or cope with being off work for a year or even two because they cannot get their hip done. That is what 7 million on the waiting list means.
I will not repeat what other noble Lords have said about the length of the waiting lists. They must be fixed, but we cannot fix them without fixing what causes them. Is it any wonder that you have to wait at the front door of the hospital when you have a traffic jam at the back? The NHS and social care are inextricably bound together—how many times have we said that in your Lordships’ House—yet we are no nearer to solving the problem than we were 25 years ago. In fact, it has only got worse. As we know, people are living longer with more comorbidities. We should rejoice in that because it is an NHS success story, but, as we know, local authority budgets, which have been so constricted for so many years, are unable to provide the services we need. The problems in social care are just the same as they have always been: not enough money, too little integration and fragmented services. That is what a previous Prime Minister promised to fix. As my noble friend said, “That went well, didn’t it?”
I know that the Minister, when he comes to reply, will give us statistics on how much more money this Government have put in, but it is spent on the wrong thing: on hospitals instead of primary, community and social care, which are the services that keep people out of hospital. As the Association of Directors of Adult Social Services reminded us:
“National policy and investment has predominantly focused on addressing issues relating to discharge from hospital”—
there we go with hospitals dominating again. Consequently, people are sicker and have a higher level of need, so more resources are needed. ADASS says that we can fix this system only
“by shifting policy and investment towards early intervention and prevention”.
Hurrah for that, but preventive work—the stuff that keeps people out of hospital—is always the Cinderella when money is being dished out because it is long-term policy.
I have just had the privilege of chairing a special inquiry into integration between community and primary care services. Our report will be published shortly, and I hope it will not only give a useful insight into what the problems are due to a lack of integration are but draw conclusions about how they could be addressed.
Our focus on hospitals as the embodiment of the NHS blinds us to the other services, which are much more important to the patient and much more effective in sorting out the waiting list problem. Primary and community care services are what most people have contact with in the NHS. If we are really serious about improving NHS performance, then that should be our focus. Your community physiotherapist can prevent the need for a knee replacement, and your community occupational therapist can prevent the fall that results in hospital admission. I hope the Minister will assure the House that the Government understand the great importance of prevention in tackling any problems in the NHS.
I will mention two more elements in the NHS that we ignore at our peril when it comes to performance. The first is the voluntary and community sector, which provides so many services that contribute to good health, both mental and physical: the plethora of disease-specific organisations, support groups and information services, which are vital and make such an important contribution in healthcare, as we saw during the pandemic, that are now under threat because of a lack of funding from local authorities and pressure on their volunteers. Only one-third of directors of adult social services were able to invest in community and voluntary services.
Secondly, your Lordships would expect me to flag up the vital contribution of families to health care—those millions of unpaid carers. I quote from the State of Caring 2023 report from Carers UK on carers’ health and well-being. The report shows that
“carers’ mental and physical health is getting worse, and for some it’s at rock bottom”.
It says that
“42% of carers said they needed more support from the NHS or healthcare professionals, and …better recognition from the NHS of their needs as a carer”.
The report also says:
“35% of carers said they were waiting for specialist treatment or assessment, either for themselves or the person they care for”,
and that they were therefore worried about their ability to go on providing that vital amount of care. One carer, talking about the challenges with their mental health, said:
“I know I could ask for counselling, which I’ve had several times over the years through my GP and other organisations. But the waiting lists are very long”—
too long for me.
The Government’s vision should be that we have an NHS which is the most carer-friendly health service in the world, both for the unpaid carers and for the one in three staff who work in the NHS and are juggling caring responsibilities themselves. I hope that when the Minister replies, he will reiterate the Government’s commitment to having a clear and deliverable strategic approach to improving carers’ health and well-being, and the structures which enable carers to get the support that they so much need.

Baroness Hodgson of Abinger: My Lords, I welcome the opportunity to have this debate and thank the noble Lord, Lord Hunt, for having secured it. We are so very lucky to live in a country that has a health service, and we should celebrate the NHS on its 75th anniversary. I pay great tribute to the many dedicated doctors, nurses and health professionals who have worked in the NHS over the past 75 years, many of whom really are true heroes.
However, we are having this debate at a difficult time, as we have heard, with the NHS facing unprecedented challenges and the fallout of the pandemic still significantly impacting the system. There is also, perhaps, a generational change of attitude. I do not think we have ever before had doctors and nurses going on strike. On top of that, a number of very difficult situations have come to light, with maternity  scandals, as we have heard, in hospitals such as Shrewsbury and Telford, Nottingham, Mid and South Essex, Morecambe Bay and East Kent—to name some of them—revealing huge failings in safety, as well as the realisation that hundreds of avoidable deaths occur in our hospitals. No longer can we say that the UK has the best survival rates for many cancers. All this paints a picture that the NHS is somewhat in crisis. As we have heard, a recent IPSOS survey noted that public satisfaction with the running of the NHS as a whole is at its lowest level for 25 years.
Time is short in this debate and it is such a huge subject, so I thought I would concentrate my remarks on the GP system and primary care. We had the most wonderful system, but since the early 2000s this too seems to have dramatically declined, starting with the change to the GP contracts. The British Social Attitudes survey found that the proportion of patients who were satisfied with GP services, in particular, has plummeted from 68% to 38% since 2019, with people often struggling to get the care that they need. Anecdotally, we consistently hear about the crisis of patients not being able to access their doctors. Many GP practices have taken on the system of triaging patients, but if you are really feeling unwell, you do not feel like fighting with the receptionist to see a doctor—the result being that people give up and go straight to A&E, which naturally has a knock-on effect on waiting times there and on the ambulance service, which cannot discharge its patients.
It is clear that GPs too are feeling under pressure. A report published by the Health Foundation charity paints a picture of high stress and low satisfaction with workload. Just one in four UK GPs are satisfied with the time they are able to spend with their patients and appointment times are among the shortest of 11 countries surveyed. I gather that the average doctor now has to deal with 41 to 50 patients a day. When asked, GPs feel that the right number is somewhere around 30, maximum, and this situation is leading to burnout. Only one in four GPs in England is now working full time; most work three days or fewer each week. A third of GPs are considering leaving within five years, with the Royal College of GPs claiming that it is “no longer feasible” to be just a GP, despite an average salary of over £100,000 a year.
Many doctors now do not know their patients. Talking to older GPs, I learned that the job satisfaction came from knowing whole families and caring for them throughout their lives. While not knowing your doctor may not be a problem for the young and healthy, if those with small children or the elderly know their GP that makes it much easier for the GP to treat them, without having to read through all their notes each time, thus cutting their time down. I have cited in previous debates the Norwegian study published in the British Journal of General Practice, which clearly demonstrated the benefits and stated that it can be lifesaving to be treated by a doctor who knows you.
Yet in the UK, GP practices are becoming bigger and the relationship between doctors and patients less constant. While patients over 75 in the UK are given a named GP, it would appear that some doctors interpret this as just having to look at patient records. I understand that patients who wish to be seen urgently cannot  always see the same GP that day, but how can a doctor deliver appropriate and responsible care to a patient without ever meeting them?
What can we do, going forward? I believe we need to redesign the whole system so that it works for doctors and health professionals, and, most importantly, for patients. Training more GPs is one easy answer. I know that there was an increase of 25% in funded medical school places in the three years up to 2020, but clearly we need more. We must cut down the number of patients who doctors are being asked to see each day. We must make it advantageous for doctors to work in a practice, rather than being a locum. Smaller practices used to work better. Most importantly, we need to encourage doctors to know their patients again; this will lead to better outcomes, as shown by the Norwegian study, and help ease pressure on the whole system.
However, we need to do more to encourage people to take responsibility for their own health. Prevention is key: good diet and exercise are vital; health checks are important and should go on until an older age. We should also include mobility checks, as people who cannot exercise will put on weight, leading to diabetes, heart problems et cetera. That would help to prevent hip and knee problems. We need to encourage practice nurses to deal with more conditions and get qualified pharmacists to be able to give a wider selection of medication without a prescription. Community nurses are such an asset, and we need to ensure that doctors work closely with them. Those dealing with patients on the phone need to be trained to be kind and caring.
Mental health takes up more and more time. Are there better ways of dealing with this, rather than endless medication? Should we encourage people with certain conditions not to go first to their GP? For example, could those with back pain go first to an osteopath or a physio or a sports therapist, who can often sort them out? Good IT can really help with the whole system.
We must make sure that primary healthcare works better for patients, as well as being a job that is once again enjoyed and valued by doctors. This is so important, as, if we can once again restore good primary healthcare, that will ease the whole health system.

Lord Prentis of Leeds: My Lords, 2023 is the year we celebrate 75 years of our National Health Service, and what is crystal clear, above anything, is the continuing strength of people’s attachment to our NHS. The vast majority of people—nine out of 10—believe that the NHS should remain free at the point of delivery, while eight out of 10 continue to believe that the NHS should be funded through taxation. This support extends across all political parties, across leave and remain voters, and across all age groups—and for me, personally. Twenty years ago, like millions before and after me, our NHS saved my life, and for that I will always be grateful. The health service is still there for all of us, 75 years on, from cradle to grave.
How did it come to be that the waiting list for treatment will exceed 8 million by December 2024? How did it come to be that the number of patients  waiting for treatment and suffering real harm could double in three years to 7,900? We need to look no further than the recent OECD Health at a Glance 2023 report, whose international comparisons showed that the UK has among the lowest average growth in per capita health expenditure. We need look no further than the Care Quality Commission’s own works warning of the dangers of longer waits and reduced access, especially in maternity, ambulance and mental health, as already referred to.
We need look no further than this House’s own investigation earlier this year. The report was called Emergency Healthcare: a National Emergency. Emergency healthcare is facing a crisis. To quote from our report:
“Patients are delayed at every stage of trying to access emergency healthcare … Stories of ambulances being stuck outside of hospitals”,
which is “posing an unacceptable risk”. The impact on the workforce, according to the same report, is that there are
“significant challenges, including shortages, low job satisfaction and retention rates, and poor health”.
Ambulance staff were described as “overwhelmed … fatigued and depleted”. Our NHS is under unprecedented strain and our own House of Lords report drew attention to the 133,000 vacant posts in the NHS and the 91,000 vacancies in acute social care.
Anyone who uses NHS services knows that they are only as good as the staff who are treating them. These are workers who were on the front line during the long months of the Covid crisis. Many left—exhausted and shell-shocked by what they went through. If our NHS is struggling with the huge gaps in staffing and is struggling to motivate those who remain, our NHS will always struggle to deliver the quality of care that it wants to.
However, there is some good news on the horizon. The NHS Long Term Workforce Plan has finally, after many years, been published. Much of the plan is positive, particularly the focus on boosting the use of apprenticeships. But even this plan was massively delayed. Now, the challenge of providing a thriving and sustainable NHS workforce for the future has become even greater.
The biggest problem with the plan, as with so much of healthcare policy, is a continuing failure to provide any solution to the deteriorating situation in social care. The state of social care is appalling, with the number of vacancies now reaching 152,000 in England alone. It is a service kept alive by the use of migrant labourers, who legally can be paid 20% less than the existing workforce. There is now growing evidence of widespread exploitation of migrant staff in the social care sector. There is growing evidence of care workers from overseas having money deducted from their wages to cover dubious fees, facing demands to repay thousands of pounds when they try to move jobs and being forced to pay extortionate rents for sub-standard accommodation. It is an adult social care service that is not fit for purpose and is causing gridlock at the interface with the National Health Service.
As the Government have prevaricated and delayed, so the sector has moved further into crisis. There are questions that must be answered. We have a long-term workforce plan for the NHS, but why is there no corresponding social care strategy? We have a successful  NHS social partnership forum, but why is there not one for adult social care? Why are the Government willing to participate in the NHS forum but stand aloof—conspicuous by their absence—from a social care forum?
What is needed more than anything is ambition and a proper overhaul of the adult social care system. In short, we need the introduction of the national care service that we on this side of the House are calling for. The vision that led to the creation of our NHS is as valid today as it was in 1948. Today, it treats 1.3 million people per day. It is productive, despite little investment in capital works. It gives value for money, but, as demand increases, so do the pressures. Innovation is vital—that goes without saying—but so is the NHS long-term workforce plan. NHS England believes it could mean an extra 60,000 doctors, 170,000 nurses and 71,000 more allied health professionals by 2036.
Such a transformation will be achieved only if the Government of the day have the ambition to see the plan as their priority and provide the resources needed. The vision that underpinned our NHS has stood the test of time. We have all benefited from the courage of those involved in 1948. It is our duty now to ensure that our NHS continues to evolve so that it is there for future generations. Like everybody, I would like to quote from Aneurin Bevan. My favourite quote has nothing at all to do with the NHS, but Nye Bevan said this, and I have always used it as a way forward: “If you walk down the middle of the road, you get run over”.

Lord Brooke of Alverthorpe: My Lords, I am grateful to my noble friend Lord Hunt of Kings Heath for his—as expected—truly amazing speech. He is a man with great experience of the health service, both before he came into this House and, in particular, while he was serving here as a Minister. He is a man of great value; he is one of the few politicians around who resigned on principle on an issue. He resigned over Iraq. I was one of those who was on the wrong side and I admire him greatly for the work he has done and what he continues to do.
As he mentioned—as did the Baroness, Lady Pitkeathley—I also spoke on this way back in 2003. I also spoke in 2018, when we were celebrating 70 years. What particularly interested me then was that the standing of the NHS in the eyes of the public was very high. I thought it was a great opportunity for us to try to take this jewel. The NHS is something which binds us together. As the previous speaker just said, it is important that we go back to that and find ways in which the public attitude, as it presently stands, is reversed.
I suggested in 2018 that we ought to think about creating a national charity for people to participate in and leave gifts in their wills to, and so on. The Government said no, because some trusts already have their charities and that would undermine them. Well, some trusts do have them and they are very successful, but, if you examine it, you will find that the ones getting great amounts of money are in wealthy areas. In the dispossessed areas, where we have the worst health and growing  rates of ill health, you will find that charities either do not exist or, if they do, not much money is going in. I would be prepared to put something in my will—not for Chelsea and Westminster, which I am close to, but for the NHS. The money would then be redirected to the areas of poverty where we need to be making the greatest changes.
If we look at what is happening, as my noble friend Lord Hunt pointed out, we are starting to see for the first time in near history that life expectancy is halting and going in the other direction. If you live in Westminster, your life expectancy is going to be of the order of 86 years, but if you are in Manchester it is down to 77 or 78—and this is happening against a background of general decline in many areas of the health service.
I hope the Minister might still give some thought to the idea that we should try to find ways of having far greater involvement of the public. The charity approach was one idea. When Alan Milburn was Secretary of State, he tried to find ways to get more people involved. They even explored the idea of shares in the NHS, so that people were making a personal commitment to it. I still believe there is merit in going back to some of those issues.
Covid has of course made a difference, and we should not deny that—the Minister will, without a doubt, labour this point in defending the state we are in. When we came into power in 1997, the health service was in a mess and, as was said, it is in a mess again. We have to find our way forward. Care in particular has to be addressed, and we have a plan there, but I believe that the way forward will be to try to involve more people in building a base for revising our approach to it. I appeal to the Minister: the Government made promises in 2019 but have not delivered on anything, so would they be prepared to consider working closely with the new Government, if Labour comes to power, to try to take care out of the Punch and Judy that we have had so much in the past—to come together and to shift care away from political disputes between the parties? I hope the Lib Dems might be willing to give their support to that entirely different approach to care, because it is so desperately needed.
I wonder why this review of Covid is going on until 2026. How much money will be spent on it before it is completed? Would it not be better spent on trying to address some of our current problems in the health service? With Covid, some underlying causes needed addressing. The first was age—and care is the way we start to address that properly. The second was the underlying cause of weight: 50% of the deaths attributed were attached, for a variety of reasons, to people being overweight. The Government have a number of proposals for change, but have fallen well short. They made a grave mistake in winding up Public Health England—at least it was seen as a focal point for campaigning, and it was coming out with strategies that were noticed. We have completely lost focus on where we go in campaigning on obesity, and I hope that, when my party comes to power, it will address that more than it has been addressed in the past. The third area that was identified in the Covid review was the disproportionate number of people of colour who suffered badly. As  was mentioned, a recent report says that people of colour are still gravely disadvantaged in health terms compared with the white population. We need to find new policies to address that difficulty and to turn it around so that people start to feel that they are a better part of the community than they are now.
My appeal overall is to try to take certain areas where we are failing to make progress out of the Punch and Judy of politics, to develop new relationships that would move us forward on issues that we have all had policies on for years but have not made progress on. I hope the Minister spends some time, in responding, on the need to get the public more involved than they have been and to get some unity of purpose between the parties in the areas where we have still not made any movement but should have.

Bishop of London: My Lords, I declare my interests in the register. It is a privilege to participate in this debate about one of our most valued institutions and to follow some excellent contributions. One of the focuses of my work in this House has been reducing health inequalities. The NHS was founded in the face of extreme inequality, in the hope that financial means would not be the sole determinant of health. The universal service that is free at the point of use is something we can be extremely proud of.
The 75th anniversary of the NHS is very close to the 75th anniversary of the Windrush generation, which I will celebrate today. As we know, many of the passengers on HMT “Empire Windrush” took up roles in the NHS, which launched just two weeks later. When experiencing workforce shortages from 1948 onwards, British politicians visited the Caribbean as part of a recruitment programme that had 16 agencies in the British colonies by 1955. By 1977, 66% of overseas student nurses and midwives originated from the Caribbean. In the face of overt racism and unequal opportunities for professional development, their contribution has been truly extraordinary. Without it, the health service would not be what it is today.
I am sure much of our nation would say that the true treasure of the NHS is its workforce, whose example should be a great encouragement to all of us. In this House, I have not held back from highlighting the challenges that the workforce currently face: significant vacancies, sometimes poor working conditions and enormous pressure. The industrial action we have seen is a product of the erosion of trust between the front line and this Government. Since the passing of the minimum service levels Act in the last Session, what ongoing work is being done to build relationships of trust with the unions and other bodies to ensure that the concerns and needs of the workforce are truly listened to?
As I have said before in your Lordships’ House, the global majority heritage staff continue to face troubling challenges. The Care Quality Commission’s State of Care report highlights instances of tolerated discrimination and a lower chance of being represented in leadership and managerial roles. There are over 256,000 black and minority-ethnic nurses and midwives, but they are overrepresented in bands 1 to 5. When I was the  Government’s Chief Nursing Officer for England, I commissioned the government Chief Nursing Officer’s black and minority-ethnic advisory group, which it was a joy meet with on its 22nd anniversary. The most recent race equality standard report from the NHS shows that there is progress heading in the right direction; although it is slow, it should celebrated.
Amid the celebration of this great institution, many challenges remain. The strain placed on the service is clear in key areas, including the number of people waiting for care and the significant workforce challenges. But there are also challenges with our health, distinct from our healthcare. Some 50% of people in the most deprived areas report poor health by the ages of 55 to 59, which is over two decades earlier than in the least deprived areas. It remains an injustice that where exactly you live can change the length of your healthy life in such a serious way. In light of this, what consultation has taken place with other departments to seize the opportunity of the Major Conditions Strategy to give new focus on health inequalities?
It is good to see the new integrated care systems becoming more established. I hope that we will see real progress in place-based and community-focused preventive care. Research published recently by the NHS Confederation shows that every £1 invested in community and primary care brings back £14 to the economy, compared to £11 per £1 for acute services. It is through working for a healthier population that the pressure will be lifted off the NHS and the opportunity to address health inequalities will be realised. I commend the small-scale projects happening in London, where I am. The community health and well-being worker model, which is being rolled out in Westminster, is already encouraging the uptake of health screenings that would otherwise not happen, management of low-level health conditions and promoting well-being. There is much to celebrate about the NHS but, as we have heard, there remains work to be done if we are to press ahead in the same spirit as the architects of the NHS 75 years ago.

Lord Cashman: My Lords, it is a real pleasure to follow the right reverend Prelate the Bishop of London, particularly given her experience in the NHS—and, may I say, her recent intervention in Synod on the issue of same-sex unions. It is also good to look around the House and see Members wearing the red AIDS ribbon, a powerful reminder that tomorrow is World AIDS Day and of what research, awareness-raising and the saving of lives can bring about when we work together. I particularly congratulate the Government on the Secretary of State’s announcement yesterday on increasing opt-out testing for HIV/AIDS and hepatitis C. That brings me to my first point, which is that it is vital that we do not forget the lessons learned from the recent Covid pandemic and the importance of simple but effective preventive public health measures in helping to protect the NHS against the financial and logistical burden of seasonal and other infectious diseases.
Ministers will recall that a targeted hygiene approach was applied to control transmission of Covid-19 and other infections in public areas, at COP 26 in Glasgow, and at the 2022 Commonwealth Games in Birmingham.  The approach was extremely successful. If the Government were actively to promote targeted hygiene among the public and with owners and operators of public spaces, it could deliver a threefold benefit: building public confidence in using communal spaces and, by preventing illness, reducing pressure on the NHS and boosting productivity in the workforce.
This brings me to my second concern: the complications following aesthetic surgery procedures abroad, a service now widely advertised in the United Kingdom. Demand for cosmetic surgery is increasing year on year. Recently in the United Kingdom, the British Association of Aesthetic Plastic Surgeons, or BAAPS, in its 2022 national audit, reported a 102% increase in cosmetic procedures performed nationally, accompanied by a growing trend in patients seeking cosmetic surgery abroad, resulting in an increase in complications on their return. The BAAPS 2022 audit found a 44% increase in complications following cosmetic surgery abroad, including life-threatening concerns necessitating emergency surgical debridement and intensive care admission for sepsis.
This national concern is twofold: first, the increased burden placed on the NHS; and secondly, the physical and psychological burden placed on the patient. The true burden on a young working female demographic has seen increased incidence of lost workdays, significant side-effects of renal impairment, hearing loss from antibiotics, repeat theatre visits to valuable emergency theatres, and A&E visits. There is also a real concern about the true cost to the nation and the NHS arising from multi-resistant bacteria. This is in addition to cosmetic deformity and psychological issues from permanent scarring.
There are many factors influencing patients’ choosing cosmetic surgery abroad, but there is little public awareness of the incidence of complications following such surgery abroad and the additional financial burden incurred on seeking treatment and corrective procedures, both privately and in the NHS. Study proposals are being drawn up by the British Association of Plastic, Reconstructive and Aesthetic Surgeons. The aim of this service evaluation, as the Minister may know, is to obtain retrospective and prospective data from all plastic surgery units in the United Kingdom relating to recent NHS and private clinic admissions for complications following cosmetic surgery abroad, the management of surgical and non-surgical treatment, and the country in which the primary surgery was performed. Therefore, I urge the Minister and his department to engage with BAPRAS on that proposal, and I look forward to his response.
Finally, I end with a quote from a senior aesthetic consultant:
“Problems remain: bad days, loss of workdays, side effects of drugs to hearing, kidney and liver function, loss of life and scarring and psychological effects of cosmetic surgery that has gone wrong. The real worry will be the introduction of multi-resistant bacteria to many specialist parts of our NHS, A&E, infectious diseases, plastic surgery, ENT and general medical longer-term needs. Our NHS lacks direction and leadership, due to the political football that is the NHS and the transient nature of the managers who run it and who are responsible for the spend in it”.
That is as damning as it is concerning, and it is clearly time for urgent intervention—and I have not even touched on the deeply worrying proposal for physician assistants. Yes, let us celebrate this amazing  75th anniversary. I have much to thank the NHS for, not least the love and care of my late husband in his 50th year, at the end of his life. But while congratulating the NHS, let us also take the necessary action and decisions to assure its continuation.

Baroness Taylor of Stevenage: My Lords, it is a great pleasure to follow my noble friend Lord Cashman and pay tribute on this special day to all the work he has done on AIDS awareness. I am grateful to my noble friend Lord Hunt for introducing such an important debate to the House today, with a tour de force of a speech on the opportunities for and challenges facing our NHS.
We recently held an event in Stevenage to celebrate the 75th anniversary of the NHS, and we were privileged to be joined by my honourable friend the shadow Secretary of State for Health and Social Care. During that occasion, we looked back to days before the NHS existed and the insecurity that working-class communities experienced when their health failed. Ill health could bring about disastrous consequences for families not able to afford treatment, and home treatments and remedies often made matters worse—a situation, I can tell the noble Lord, Lord Lexden, that existed hundreds of years before a Labour Government introduced the NHS. We reflected on the current situation the NHS faces: the marvellous and heroic dedication of the staff being tested daily by increasing demands; an epidemic of mental health issues; digital and pharmaceutical treatments that are incredibly effective but extraordinarily expensive; and an ageing population. Then we considered what the future of the NHS might be with the development of AI technology, robotic surgery, and the aspect I would like to concentrate on for the purpose of this debate—a much clearer focus on prevention. But that will require considerably more partnership working, especially, but not exclusively, with local government, which is what prompted me to take part in this debate.
Local government has always played its part. The first Public Health Act was passed as far back as 1848, and much of the drive to local governance in Victorian times was exactly to tackle the public health issues arising in the overcrowded and squalid living conditions of Britain’s working cities. As recently as 2013, those responsibilities came to the fore again when public health commissioning was transferred from the NHS to local authorities, which took on responsibility for improving health in their local populations, including services to reduce drug and alcohol misuse, social prescribing, promotion of health and well-being through their leisure facilities, and direct intervention to tackle prevention priorities such as smoking and obesity.
An excellent report co-produced by the District Councils’ Network and the University of East Anglia showed that the engagement of just over 1 million of the inactive population of England in prescribed leisure services could provide significant outcomes over a 10-year period, such as 45,000 diseases avoided, giving a direct saving to the NHS of £314 million; 70,000 additional years of life in good health, with an economic value of £4.2 billion; and a reduction of 3.7 years in the healthy life expectancy gap.
In my own area, we set up a healthy hub to deliver rehabilitation programmes following strokes, cardiac episodes and cancer treatment. More recently, we instigated a young persons’ healthy hub to support our young residents, especially with their mental health issues. These services now sit alongside the adult and social care services which we have heard so much about in this debate and which are so key to keeping our vulnerable residents healthy and our hospital beds available to the most acutely sick. I hope no one here would deny the enormous role played during the Covid pandemic, as local government developed our relationship with our health partners even further to support our communities through the worst healthcare crisis for generations.
All this work in partnership with health colleagues is very much part of the NHS aim to deliver healthy communities. The figures are clear: it is set out in a report from the Public Accounts Committee that community sport and physical activity, such as social prescribing, brought an estimated contribution of £85.5 billion in social and economic benefits, including £9.5 billion from improved physical and mental health. The part played by local councils in saving costs to the NHS can hardly be disputed, but we have had cuts to local government funding, which has seen a 27% real-terms cut in core spending power since 2010, and the LGA predicts that councils will face an eye-watering £3.5 billion funding shortfall over just the next two years to keep services standing still. Councils’ role in preventive healthcare, public health, and adult and children’s social care, both of which face extreme pressures, is in jeopardy.
Much of healthcare, such as social prescribing, rehabilitation and preventive programmes, is delivered through council leisure functions but—it is a big “but”—most are funded as discretionary spend. The Public Accounts Committee warns that 70% of councils are considering scaling back their leisure services, not least because their energy bills have seen an increase from £500 million in 2019 to £1.2 billion last year. This comes on top of over £71 million already cut from leisure budgets since 2010, a 14% cut. Most sporting facilities in our towns and cities have an average age of over 30 years, with no funding available to improve or replace them.
Councils and councillors want to go on playing their part in supporting our NHS to keep our communities healthy and to tackle health inequalities. Indeed, the King’s Fund recently said that councils have a fundamental role in determining the health of their communities. But while relationships with the NHS are strong and the political will is there, the funding model is incredibly fragile and, should it come tumbling down, the consequences in additional costs and demands, both short and long-term, to our NHS are extremely serious. I hope that the Minister will persuade the Chancellor to consider this as he finalises the local government funding settlement in the next couple of weeks, and to invest to save in local government, in prevention and in a healthy future. As Nye Bevan said:
“There is no test for progress other than its impact on the individual”.

Baroness Tyler of Enfield: My Lords I start by expressing my heartfelt thanks to all NHS staff for the tremendously difficult and important job they do. I particularly pay tribute to the memory of close to 1,000 NHS and care workers who died while working to save others during the terrible Covid pandemic. We owe them a debt of immense gratitude. Like other noble Lords who have spoken today, I know that I and other family members owe our lives to the NHS, and that is why it holds such a central place in our country’s social fabric and in our hearts.
It is against that backdrop that I want to talk about the need for reform. As we mark the NHS’s 75th anniversary, it is right that we should reflect on its performance and what could and should be done to improve and renew it. We have already heard a lot of statistics about waiting times and numbers treated; I want to concentrate on the wider context for health and then look specifically at the thorny question of productivity.
It has been estimated that some 80% of the health needs of people across the country are not within the direct control of the NHS. We also see large inequalities in health outcomes between different groups and communities. The terms “NHS policy” and “health policy” are too often used interchangeably, but they are not interchangeable. Most policy which impacts the health of the nation—housing, transport, employment and so on—is made outside the NHS, which is why we need to focus on the wider determinants of health and devise cross-government strategies to improve health and well-being. It is also why it is so important to ensure that more money goes into prevention and public health rather than just into the NHS, a point just made so compellingly by the noble Baroness, Lady Taylor of Stevenage. Looking at health and well-being in the round, rather than simply at how we prop up the NHS in its current form, must be at the forefront of our thinking. We have already heard, and it is very concerning, that public satisfaction with the running of the NHS is at its lowest level in 25 years.
What is going on? In July this year, the chief executives of three health think tanks, the Health Foundation, the Nuffield Trust and the King’s Fund, wrote a letter to the three party leaders calling for an end to “short-termism in NHS policy-making”, warning that promising unachievable, unrealistically fast improvements without a long-term plan to address the underlying causes of the current crisis is a strategy “doomed to failure”. We would do well to heed that. The letter outlined four key areas to focus on: investing in physical resources; reforming adult social care; committing to a long-term workforce plan; and cross-government working on the underlying economic and social conditions affecting health.
Specifically, the letter pointed out three things. First, due to a decade of underinvestment compared to the historic average, and capital spending well below comparable countries, the health service has fewer hospital beds than almost all similar countries, outdated equipment, dilapidated buildings and failing IT. Secondly, despite long-term objectives to reduce reliance on acute hospitals and move care closer to the community,  which I very much support, spending continues to flow in the opposite direction. Thirdly, while the NHS long-term workforce plan is to be welcomed, ambitious steps to increase the number of staff, through training, apprenticeships and international recruitment, et cetera, risk being frittered away if trainees continue to drop out and poor morale and sickness continue to drive staff to leave and retire early. In short, sustained action is needed to make the NHS a better place to work.
Finally, as we have said so many times in this Chamber, we cannot reduce pressures and improve the performance of the NHS without addressing the challenges faced by adult social care. I join the noble Lord, Lord Prentis, and ask, once again, what plans the Government have to provide a social care workforce plan to complement the NHS plan?
It is also worth comparing the NHS to the healthcare systems of other countries. The King’s Fund did this recently and concluded that, first, the NHS is neither a leader nor a laggard when compared to the health systems of 18 similar countries. Secondly, the UK has below-average health spending per person compared to those countries. Thirdly, the UK lags behind other countries in its capital investment and has substantially fewer key physical resources than many of its peers, including CT and MRI scanners and hospital beds. Finally, the UK has strikingly low levels of clinical staff, including doctors and nurses, and is heavily reliant on foreign-trained staff. All that is critical to productivity, which I want to turn to finally.
Respected commentators such as the IFS, the Institute for Government and the Health Foundation have been looking at what has been called the productivity conundrum. The Institute for Government report The NHS Productivity Puzzle found that despite increased spending, particularly since 2019, much of which has gone on increasing staff numbers, there has not been a resultant rise in productivity if measured against metrics such as the number of patients treated. It draws three conclusions. First and foremost, hospitals are running at above full capacity, they do not have enough beds, and too many of the beds they do have are full of people who should not be there. There is a lack of capital investment, low diagnostic equipment stocks, et cetera. Secondly, despite notable increases in the headline number of staff, the NHS is losing too many experienced employees, and they are being replaced with more junior people who are naturally less experienced and who need more support. Staff burnout, low morale and pay concerns are cited as key reasons. Thirdly, it says, the NHS is badly managed and all the changes over the last decade have made managers’ jobs a lot harder.
Finally, a recent IFS report came to similar conclusions about the reasons for the low productivity. It acknowledged it was difficult to measure productivity, and that point came out clearly when Amanda Pritchard was before the Health and Social Care Committee recently. She argued that it is hard to measure productivity, but what plans do the Minister and NHS England have to publish their own analysis of NHS productivity and ways to improve it?
There is much that we could and should be doing. My points and the IFS statement should not be interpreted as NHS staff working less hard. It is the other points that are most important. I expect they are many reasons, but the need to make the NHS an attractive place to work is critical and should be central to the NHS workforce plan.

Baroness Crawley: My Lords, I too thank my noble friend Lord Hunt of Kings Heath for introducing this debate. Few are more qualified to discuss the significance of the 75th anniversary of the NHS than he is.
It was a sometime Conservative Chancellor who once described the NHS as a “national religion”. It must pain some of my colleagues on the Government Benches to see the extent to which the Government appear to have lost faith in that service and that religion. Anyone who read the recent Autumn Statement could reach no other conclusion. What is the old lyric? “They are only putting in a nickel, but they want a dollar song”.
Let us deal with the realities. As we have heard from noble friends and others in this debate, according to the BMA, some 7.8 million people are currently on NHS waiting lists. Over 3 million of these patients are waiting over 18 weeks. People who can ill afford it are pursuing private health provision instead of risking the long wait, as we saw last weeks in the figures that came out from the eye care sector. There are millions of people living in constant pain and worry, with no immediate alleviation to hand, including older people and their families waiting in bewilderment for dementia diagnosis and support. As a Dementia Friends ambassador, I know that support is so ad hoc and threadbare across different health authorities that the national infrastructure is just not there to implement any future medical advances in Alzheimer’s and dementia. Young people who cannot find peace of mind wait far, far too long for mental health services.
What does the Chancellor say to all this in the Autumn Statement? He says:
“That is why I want the public sector to increase productivity growth by at least half a percent a year—the level at which the size of our state starts to reduce as a proportion of GDP”.—[Official Report, Commons, 22/11/23; col. 328.]
What is he saying? “Let’s not worry about the industrial action of recent times. Let’s not be troubled by the healthcare buildings infected by crumbling RAAC. Let’s not be dismayed about the Government’s vanishing new hospital-building commitments. Let’s not fret about the stresses on beleaguered staff. Let’s just make nurses and doctors work so much harder in order to achieve our ideological goals”. As my noble friend Lord Hunt said, you could not make it up.
I invite the Minister to share this pledge: that nobody, in any part of this country, should ever be treated in a hospital corridor. If that is not a government objective by now, we certainly need a new Government. Meanwhile, I have to agree with Professor Ranger of the Royal College of Nursing when she commented on the Autumn Statement, saying:
“The NHS faces a multi-billion pound deficit—giving away at least £5 billion in tax cuts in place of health spending confirms the NHS is no longer a priority for the government”.
Let those words sink in: “no longer a priority”. A fit for purpose NHS seemingly does not fit with the Government’s ideological scheme of things. Even the NHS Confederation, hardly His Majesty’s Government’s greatest critic, had this to say about the Statement:
“There were no new major funding announcements for healthcare and existing settlements will stay the same in cash terms”.
This is despite the Nuffield Trust estimating that the NHS faces £1.7 billion deficit. Let us face it, a Conservative Secretary of State for Health—and there have been a few—is about as welcome to health professionals at the moment as James Cleverly would be today in Stockton North.
It is, we are told, the Chancellor’s stated goal to boost productivity in the UK—and so say all of us. Can one think of a faster route to increase productivity, as noble Lords have said, than a healthy workforce with few anxieties about seeing a consultant or getting treatment for a loved one?
The NHS is now 75 years old and remains probably our most stirring national achievement, the envy of the free world. This septuagenarian should invite both respect and support—and it does not appear to be getting either from this Government at the moment.

Lord Davies of Brixton: My Lords, I join other speakers in thanking my noble friend Lord Hunt of Kings Heath for initiating this debate. I am going to focus on the issue of mental health and I declare as an interest my involvement with the Money and Mental Health Policy Institute. My remarks depend a lot on the excellent briefing note produced by the Royal College of Psychiatrists, and there is also the continued information provided by the BMA about the pressures on mental health services in England.
Looking back over the last 75 years, we have seen massive changes in this area. It has improved significantly since the NHS was launched. Treatment options have increased and access to treatment has improved. Most notably, of course, there was the closure of the large institutions—the asylums—and the welcome shift to emphasise treatment in the community. Attitudes have also changed. Social barriers are being broken down, mental health is being talked about more openly and positively than before, and in particular, as has been noted by NICE, young people have a different attitude and will drive the process of achieving progressive change.
Having said that, I endorse the remark made by my noble friend that it is deeply disappointing that we are still waiting for the Mental Health Bill which was first proposed six years ago. Despite all the work that has been done, the issues that prompted the reform process remain unaddressed. Detention rates continue to rise and the detention of black and racialised communities remains hugely disproportionate. I am pleased, therefore, that the Labour Front Bench in the Commons has given a commitment to introduce the Bill in its first King’s Speech, were it to win the next election. I call on the Minister to make a similar commitment. What goes in the manifesto is possibly above his pay grade,  but perhaps he can assure us that he will urge it on his colleagues as a priority should we get another term from the Conservatives.
It is worth emphasising that, even without this major legislation, there is much that can still be done to protect people’s dignity, autonomy and human rights when they are subject to the Act. I hope that the Minister will give an assurance that active steps are being taken, failing the Act achieving this objective.
I turn now to where we are and waiting lists, which are highlighted in the Motion. There are a record 1.9 million people currently on waiting lists for NHS mental health services and record numbers of children with a mental illness. One of the main reasons for this is the shortage of staff. We have a workforce plan, but we still lack the ambitious and measurable commitments to expand the mental health workforce, in both hospitals and the community. There are also significant retention challenges affecting the mental health workforce, with professionals reporting high workloads, time pressures and poor work/life balance. Especially, there is the need to address racism and discrimination in the workplace, as well as recruitment.
The problems with staffing result, inevitably, in long waits in A&E, reflecting the difficulties that people have in accessing in-patient provision or community-based crisis alternatives. On top of this, adult acute bed occupancy has not fallen below 95% since May last year. Unfortunately, one of the reasons for this is that more than one in 10 people occupying an adult acute in-patient bed are clinically ready for discharge, but, due to a lack of social care and housing support, they remain in hospital. It also means there is still an unacceptable level of inappropriate out-of-area placements, so perhaps the Minister could say something about that.
There is a special problem with children’s mental health. Over the last few years, we have seen record numbers of children and young people with mental illness. To tackle this problem, it must be recognised that the first five years of life are crucial to a child’s development and to protecting them from future mental health conditions. The Government must invest in early intervention for children and young people—that is widely recognised. The mental health of under-fives should be a priority. The Royal College has identified the need for the urgent introduction of a national network of early support hubs.
Finally, there is the need to address the long-term disinvestment in mental health estates. The mental health sector has some of the oldest buildings across the NHS, with 15% of mental health and learning disability sites built pre-1948—older than the NHS itself—compared to about half of that in the acute sector. Despite this age, and more than 50 bids from mental health trusts for the Government’s “40 new hospitals scheme”, only two were allocated to a mental health trust. Mental health faces the most substantial shortfall in capital investment in cash and percentage terms across all trust types, which is part of a sustained trend in recent years. I hope that the Minister can give us some reassurance in his reply that capital will be put where needed.

Baroness Finlay of Llandaff: My Lords, I declare all my interests as listed in the register, including having worked throughout my life in the NHS. I congratulate the noble Lord, Lord Hunt of Kings Heath, both on securing this debate and, more so, on all the work he has done in his many years of service to the health of this nation.
Perhaps we should have called this debate “In Place of Fear”, the title of Bevans’s own short book. As Gordon Brown said:
“The astonishing fact is that Bevan’s vision has stood both the test of time and the test of change unimaginable in his day. At the centre of his vision was a National Health Service … a uniquely powerful engine of social justice”.
To know where you are going, you must know where you have come from. Bevan had seen directly how the mother in the average family suffers when there is an absence of a free health service and how financial distress excludes those with the greatest need from accessing even minimal care. Yet poverty still blights our health and care, particularly when serious illness hits and the main carer in the household is a child or young person. According to Bevan:
“The collective principle asserts that the resources of medical skill and the apparatus of healing shall be placed at the disposal of the patient, without charge, when he or she needs them; that medical treatment and care should be a communal responsibility; that they should be made available to rich and poor alike in accordance with medical need and by no other criteria”.
Seventy-five years ago, so many physically and mentally wounded were returning from war, penicillin had only just become available and, compared to today, there were relatively few interventions in medicine. The concepts of evaluating the efficacy of clinical audit and the frontiers of medical research that have revolutionised practice were just a dream for many. People now want to be cared for and know that they will get better care in research-active services.
My mother-in-law, as a young GP, gave penicillin injections to a critically ill woman with pneumonia; the response was miraculous. This recovered patient gave her a teapot as a wedding present, and we still have the “penicillin teapot” in the family today. Yet now we face huge threats of antimicrobial resistance, as these precious resources have been misused. Over-the-counter sales of antibiotics in some countries and their use in animal husbandry are threatening our survival from life-threatening infections. Drug-resistant TB is now a major threat.
Some of our failure to value adequately the importance of health to the country’s economy has resulted in too little effort being put into health promotion and public health, as others have said. Yet amazing advances have been made. The polio of my childhood has almost been consigned to history, diphtheria is rarely seen here, and other vaccines have transformed disease incidence, from measles to carcinogenic HPV, and many more. Yet we still see Dr Julian Hart’s inverse care law in play, that the availability of good medical or social care tends to vary inversely with the need of the population served.
With so much more that is treatable, and with social problems creating more avoidable disorders, we must tackle the social determinants of health if we are even  to begin to tackle growing waiting lists. The NHS cannot be the final repository for all that is going wrong in society. Our collective responsibility is through care and well-being in communities, better nutrition, and through supporting people to look after their own health and to respect a health service that is not simply a demand service—it is not like online shopping.
As we push for more care in the community as people are moved out of hospital, we have to remember that the local family structure that previous generations depended on is just not there. Discharging people from hospital to loneliness does not aid recovery. Does the Minister acknowledge and value the excellent work undertaken by all those in the community, particularly district nurses and care staff, and the ever-increasing pressure on them?
We need to tackle public health more than ever, and the misinformation that blights its use and interventions. Prevention runs through everything, including preventing complications and care failures. Nye Bevan recognised that it is obviously preferable to prevent suffering than to alleviate it. We often know what to do but are just not doing it. We understand analgesics yet too few people with advanced disease are accessing the expertise they need, including in my own discipline—I declare an interest in specialist palliative care.
Our emergency departments are under such pressure that staff talk of leaving as we hit a downward spiral in access for those with greatest need. Disease does not respect the clock or the calendar. If we do not use our resources better—the greatest resource being our staff—we will never tackle increasing waits.
We live in a seven-day society so we need to make it easier for staff with children to work on different rotas, use term-time flexible hours and weekend childcare resources so that we can use our theatres with high-intensity teams, and use diagnostic scanners and so on much more efficiently. These are human resource issues. Staff at every level can care only if they feel cared for, supported in difficult decisions and valued for all they do, with meals available, on-call rooms, and private areas to have private conversations. Without the tools and the space they need to treat people and care for people, we cannot expect them to do well.
There are many apparently high-cost interventions now available that result in remarkable long-term savings. Failure to invest in these is short-termism at its worst. Investing in capital and training, as the noble Lord, Lord Hunt of Kings Heath, said, is essential. We need to rethink our health economics model to ensure that we meet need, in the short and long term. There are different ways of working. Technology can help but it is not the only answer to current issues. A healthy nation is a productive nation.

Lord Dubs: My Lords, exactly 75 years ago today, I was as a child ill in Stockport infirmary, and I am totally taken by the memories of that day. In the morning, the consultant came by with his entourage of doctors, matrons, and so on. Consultants were very important in those days; they still are, but in those days, one did not speak unless one was spoken to. I said to him, “Excuse me—I have a question to ask”. He turned around. “What is it?” “Are we having a  party today?” He asked, “What for?” I said, “The hospital is ours—it’s a great day”. He was not very impressed and walked on. Later on, they asked me at the other end of the ward, “What’s going on?” and I explained how the hospital was ours and what a great day it was. It was a privilege to be ill on the day the health service started.
Since then, I have served on an area health authority and on a mental health trust. It is no secret that I spent two months in Charing Cross Hospital earlier this year—the danger is that anybody in this House who is asked how they are can spend 20 minutes telling people about their health conditions. I am going to resist that, except to mention it in passing. There I was in intensive care at three in the morning, it was noisy and one could not sleep. The doctor came up and looked with interest at the books I had my table—which I could not read—and she said to me, “We know who you are”. I hope I had the presence of mind to say, “Yes, but please don’t tell anybody”. This is a good moment to thank the brilliant staff, nurses, doctors, nurses, physios and cleaners of Charing Cross Hospital, who are absolutely first rate. I was delighted to remember that when the Government threatened to close Charing Cross Hospital some years ago, I had gone on every demo imaginable to save it. Little did I think that I would be the beneficiary of that campaign.
The NHS, for all its weaknesses and faults at the moment, still works well once one is in the system—I was in the system, and it looked after me brilliantly. There was also excellent follow-up; physios and OTs came home, and so for another two months I had great support. That was pretty good, and I am grateful to all those who helped. I am also grateful to the many organisations who sent excellent briefings, which are helpful for the debate today.
There is one fundamental problem, among others, for the health service. It is too vulnerable to a Government who want to cut the service and save money. It is a real political difficulty with the health service that one decision by a Government can damage it. We have to find some way around that. Perhaps having a Government who do not believe in cutting the health service is the simplest answer.
There is another problem: the imbalance between those of us who are lucky enough to be ill in London and those who are unwell in other parts of the country. We are so lucky, if we are ill in London, to have excellent hospitals very close. In other parts of the country—I know the Lake District pretty well—it is a long way to a hospital and the quality is perhaps not quite as good as it is in London, where we are pretty fortunate.
Social care has been mentioned by my noble friend Lady Pitkeathley, who has spent a lot of time campaigning for better social care. In my experience, the people getting discharged are the ones who have family support in their homes. People who do not have family support are taking up hospital beds because there is not that much social care support. We cannot say enough about voluntary carers, the millions in this country who work for a pittance—I think it is £75 a week—and who keep this country going. We owe them such an enormous debt.
My son has MS. That has made me clear that MS needs far more focus. We need more neurologists. In France and Germany, there are seven neurologists for every two in the UK. We have a paucity of experienced neurologists and we are way down the list of countries. There is therefore a legitimate claim that there should be a neurology task force, as many NGOs working in this field say, to pull all this together: the NHS, social care, professional bodies and the voluntary sector. I also make a plea for MS nurses or neurological nurses. I believe they would not be an extra cost burden but would save money, because they would provide one place where people suffering from MS could go to get help, probably reduce the pressure on GPs and might be good value for money.
I say very clearly, in case there is any misunderstanding, that what I am about to suggest is not Labour Party policy—they are all sitting up on the Front Bench. It is certainly not Conservative policy. We are obsessed with saying that we must reduce taxes. I am obsessed with improving public services. We cannot have the two together. For all the propaganda that taxpayers want the money in their pockets because it is their money, it is also our health service and our public services. My living standard, my quality of life, probably depends much more on public services than it does on whether the taxman takes a bit more money from me or not in a particular year.
I repeat that this is not Labour Party policy, in case anybody starts hitting it on the head with this one. I do not see how we can deal with the difficulties in the NHS without providing more money for it. One obvious way is to have an increase in income tax, hypothecated to the NHS and social care, so that we can say to people, “Yes, we want you to pay a bit more, but every penny of that extra money will go to the NHS and social care”. We would all benefit much more from that than from this obsession with cutting taxes. That is my suggestion.

Baroness Donaghy: My Lords, I thank my noble friend Lord Hunt of Kings Heath for initiating this debate. There are three factors which will ensure that the NHS survives, and the Minister has no control over any of them: finance, social care and decently funded local government. The NHS Confederation has said that that constitutes 80% of health needs, so we are really talking to the Minister only about the remaining 20%. The levels of funding are below those needed to serve an ageing society. It is as simple as that. The absence of long-term funding cycles prevents capital investment. The NHS Confederation states that nine out of 10 health leaders believes that underinvestment in capital is undermining their ability to tackle elective backlogs.
The Government’s complete failure to fix social care has led to acute problems around hospital discharge and an increase in human misery and fear. No sustainable system for care homes means unexpected closures for some and private equity landlords for others. Local government has more and more responsibility piled on it for less and less funding. Whatever happened to the civic pride in the Conservative Party? Without a sustainable local government service, the NHS will  continue to bear the brunt of social care failings, and the population will continue to experience inequalities in treatment.
I am sure that other speakers have received numerous briefings; my noble friend Lady Taylor referred to some of them. I appreciate the trouble they have taken and thank the House of Lords Library for its background document. Even allowing for their individual advocacy, they reveal the deeply worrying state of the NHS, whether in capital spending, mental health, skills training, cancer treatments, maternity care or the virtual collapse of GP and dental services in some areas.
I will speak about osteoporosis, to which the noble Lord, Lord Lexden, has already referred. We know that there were talks between the Department of Health, the Treasury and the Royal Osteoporosis Society about funding fracture liaison services in the Autumn Statement. The Minister, Maria Caulfield, made a commitment to action by the end of the year. As the noble Lord, Lord Lexden, said, the noble Lord, Lord Evans of Rainow—who I see in his place—announced in a debate initiated by the noble Lord, Lord Black of Brentwood, that osteoporosis care would be improved, saying that the Government were
“proposing to announce, in the forthcoming Autumn Statement, a package of prioritised measures to expand the provision of fracture liaison services and improve their current quality”.—[Official Report, 14/9/23; col. GC 241.]
However, that statement was withdrawn 24 hours later.
Come the Autumn Statement, it became clear that Ministers had broken their promises to fund fracture liaison services as it contained no references to fracture liaison. NHS England has also confirmed that no expert steering group has been set up or is even in the planning stage. Osteoporosis has been excluded from the advisory groups and working groups of the Government’s major conditions strategy despite being the fourth-worst cause of disability and premature death. Failing to deliver on what was thought to be a commitment will waste £88 million on preventable fractures, including 150,000 hospital bed days. Every year, 81,000 working-age people suffer fractures due to osteoporosis, with a third quitting their job due to long-term pain and disability. If the Government honoured their promise, 74,000 fractures could be prevented in the next five years, including 31,000 life-threatening hip fractures. What plans does the Minister’s department have to honour the ministerial promises made on osteoporosis?
My direct experience in the health service is varied. I was a ward orderly in the 1960s in a Warwickshire hospital, traipsing up and down wards with a cow gown on and pulling a trolley of urine bottles—I must admit, I felt like the bee’s knees in those days. I went on to become a non-executive director at King’s College London and a champion of elder care. However, I still cannot quite get over being older than the National Health Service. I know that the Minister cannot do anything about that but, with the 20% of things he can do something about, can he improve osteoporosis care or is he effectively reduced to rifling in that trunk in the attic marked “reorganisation, reconfiguration, privatisation, efficiency gains and distance medicine”? He is a hard-working and sincere Minister who commands  the respect of the House—at least this side of the House. I hope that his expertise will continue to be used in whatever happens in future.

Lord Drayson: My Lords, I thank my noble friend Lord Hunt of Kings Heath for securing this debate and for his truly excellent speech. I draw the House’s attention to my declared interests and previous experience, including my current roles at Appella AI and Freevolt Technologies Limited and my previous roles at Sensyne Health plc, PowderJect Pharmaceuticals, the University of Oxford, the BioIndustry Association and the Royal Navy, as I will speak on procurement of technology and innovation in the NHS.
As we have heard today in this debate, there is now compelling evidence and widespread concern about the declining performance of the NHS. Often, the adoption of new technology, including most recently AI, is cited as the key to improving standards of care and NHS productivity in future. Statistics highlighting the inferior levels of technology in the NHS compared with other countries, such as in the low numbers of MRI and CT scanners and proton beam machines, the obsolete software systems used by NHS trusts and anecdotes about paper records and fax machines, provide clear evidence that the NHS is a laggard in adopting modern healthcare technology.
Poor procurement of technology by the NHS is at the heart of the problem. It is currently a balkanised and fragmented process across the hundreds of trusts and other siloed groups involved in procurement at the national and local level. It lacks a joined-up approach based on evidence and it lacks a clear, long-term strategy. There is a shortage of expertise in the NHS in technology adoption and management, and an overreliance on external management consultants charging huge fees. Failures in NHS procurement not only undermine the quality of care and waste taxpayers’ money but create a barrier to businesses and investors wishing to invest in UK healthcare.
Life is particularly hard for small companies, which are often the shock troops of innovation. The unwillingness of NHS trusts to accept evidence from other trusts means that companies spend ages repeatedly doing pilots in multiple trusts, never getting to a critical mass of business in the UK market. It is why many investors shy away from businesses that seek to have the NHS as a major customer. The fact is that the NHS determines the fate of our UK life sciences industry, an industry in which we have a great track record of science and innovation but we lack scale. Just look at the life sciences sector on the London Stock Exchange now compared with 20 years ago; it is a shadow of its former self.
Protectionism is not the solution. We should welcome foreign companies and investors coming here, provided that they adhere to our values. However, we must care about where the work is done, where the skills are developed, where the health data is stored, where the profits are made and where the tax is paid. The recent decision of the NHS to purchase Palantir software from the US for its new federated data platform was another opportunity missed. Why did the NHS not choose a system that would help to grow our UK skills  base and a system built on open source software that would enable innovation to flourish? Why did it not choose a system that would provide confidence to patients in how their health data will be shared and used?
Much is being said about how artificial intelligence will have an enormous impact on our society in future. In fact, it is already happening, and in healthcare the effects will be profound. If the UK does not develop the onshore expertise to create software systems aligned with the values of the NHS and our society, the NHS will have no choice but to buy systems which, like Palantir’s, were developed elsewhere, with the AI algorithms trained on patients cared for under different healthcare systems. We will then import the biases and constraints that are embedded in those systems and our NHS will become less fair and less aligned with the values of our society, and the wealth created by the AI wave will accrue elsewhere.
There is a better way. Back in 2005-06, the Labour Government, in which I was a Minister, published a defence industrial strategy and a defence technology strategy that provided the Armed Forces and the defence industry with clarity on the sovereign capabilities that the UK needed. As a result, we maintained the skills and industrial capacity required to design and build submarines. Some 17 years later, not only are we still making submarines for the Royal Navy but, for the first time in years, under the AUKUS project we will soon be exporting them to our allies. That is what long-term strategic planning, backed by consistent investment in onshore skills and technology, can achieve.
We need to invest in a well-staffed, well-trained NHS procurement body that sets national standards, defines requirements and buys intelligently on behalf of the taxpayer. We need a technology strategy for the NHS, aligned with an industrial strategy for the life sciences industry, that will deliver UK sovereignty over the technology that will affect how patient care is delivered in future. These strategies will provide the global life sciences industry with clarity on what the NHS requires, highlight the opportunity for investing here, and provide our own life sciences industry with the ability to create the skills and the wealth that our economy desperately needs. Only then can we be sure that the core values of the NHS, set out 75 years ago, will survive the coming wave of technological change, deliver the high-quality healthcare our people want, and help create the wealth needed to pay for it.

Lord Allan of Hallam: My Lords, I am not able to go back to the foundation of the NHS like the noble Lord, Lord Dubs, but I will start by going back half way, to 37 and a half years ago, when I was starting to travel the world, having just left school. I got into those conversations where you compare countries, and I was asked what was so special and interesting about the NHS. I could not say that it was all public, because it has always been mixed, and I could not say that it was all free, because there have always been charges for some elements of it. The best way I found of explaining why the NHS was special was that, in the UK, we can go to bed not worrying about getting help if we fall ill in the night, or if  something happens to our parents or, God help us, to our children. That is certainly not true in all parts of the world. This reflects the promise that was in the newsreel that the noble Lord, Lord Lexden, cited at the beginning of our debate. It is a wonderful freedom that we enjoy, and it means that most of us can change jobs, move across the country, have children, and live far away from our families, all without worrying about whether those decisions will harm our healthcare and that of our families. These freedoms are underpinned by knowing that the NHS is there.
By contrast, a family member in the United States brings home to me what it is like not to have this freedom when he jokes that he has to stay with his spouse because of his health insurance—funny, but not funny. When I left my job with a US company in 2019, access to healthcare was irrelevant to my decision. It had a private health insurance policy, which meant it could get me back to work quickly because it needed me there, but I was much more interested in the free food; I did not see the private health insurance as essential because I had the NHS. I compare that with former colleagues who live in the United States or other countries, for whom the loss of their job vastly increases their health risks.
The NHS represents a significant form of freedom, but this applies only as long as it passes a key test: that we feel that it is sufficient and that we do not need something else. That proposition is holding up remarkably well, even though it has been under severe pressure many times. However, it is not certain that it will hold for the next 25 or 75 years without herculean efforts. In his introduction, the noble Lord, Lord Hunt, rightly talked about previous phases when there were herculean efforts. I was at the other end in the Parliament of 1997, and the work that Labour Ministers did then was remarkable and necessary. I feel that we are in that phase again and we need remarkable efforts to hold up.
The front-line staff have rightly been praised in this debate as critical, but I hope we also take a moment to recognise those who do the hard work of prioritisation. Administrative staff who manage waiting lists do not do fashionable or glamorous work, but it is essential to making sure that people feel that the service can deliver. Staff at the National Institute for Health and Care Excellence spend their time evaluating new forms of treatment and are often only in the headlines when they are being criticised, but their work prioritising new treatments means that that promise can be sustained. My noble friend Lady Walmsley mentioned IT staff, with whom I have a particular affinity, having been one for some years of my professional life; they keep the information flowing that allows patients to keep flowing and people to maintain confidence in the service.
There is no world in which some form of rationing of finite resources becomes unnecessary, but the key is the right allocation of those resources to where most people agree, most of the time, with the way the services are being prioritised. That is the key point I want to make in my contribution: that trust and confidence depend on not allowing the gap between people’s reasonable expectations and their actual experience of the service to grow too wide. Neither side of this equation is static, but will evolve over time.
Expectations are very different today, as we live longer and patterns of behaviour have changed, but we have also changed our expectations in wanting more information about and involvement in decisions. It is often said that the age of deference is dead. That is certainly true: we are in a very different world from 1948, when you were grateful for whatever the doctor gave you; now, people want to question and be involved in decision-making about prioritisation. My main ask of the Minister in this debate is for him to focus on that link between information and trust. It is about not data as an end in itself, but how we can turn data into useful information that feeds into a good process of deliberation, which means that we reach decisions about the allocation of NHS resources that win widespread trust and confidence.
I declare an interest in open data—I realise that I also spoke on this earlier in the week—as I am a non-executive director of the Centre for Public Data, which is a not-for-profit organisation campaigning to make more data public. I joined that organisation because of a long track record of believing in the value of open data, precisely because I think that transparency and not black boxes leads to trust in our much more inquisitive, non-deferential age.
We need to flesh out the narratives, as well, and not just get the raw data. It is interesting to know how many GPs there are—the Government just tell us that we have X number of GPs—and how many appointments they are serving but, for a complete picture, we need qualitative information, as my noble friend Lady Walmsley mentioned. We need to know how many of those GP appointments were useful, how many would have been better directed to other healthcare professionals, how many urgent consultations were stuck in a queue behind less urgent ones, and what could be done about improving the identification and prioritisation of those appointments.
I hope the Minister agrees that we need this kind of open, informed and above all honest discussion about how choices and prioritisation are done to maintain public confidence. This is not an alternative to providing additional resources, as many previous speakers have said, but is complementary to it, as people will feel that the additional resources they are putting in will really make a difference, according to their priorities for what they want to get out of the service.
On honesty and transparency, I note that the focus of the Government’s Autumn Statement on simply tax cuts, without telling us what impact they will have on public spending, was extraordinarily unhelpful. Certainly, the choices have been noted as a reflection of the Government’s priorities.
The prize here is that our children and grandchildren enjoy the same freedoms we have—freedom from worrying about getting help for their own health and about whether their elderly parents or young children will be cared for. This is a huge benefit in which it is worth investing, but it can easily slip away. Trust takes years to build, and the NHS still has bucketloads of it, despite the many challenges it has faced.
But if we as political leaders allow this trust to leak away, the drip may turn into a flood. Every detail matters in this debate, and in preventing the horrible  outcome of a lack of trust in our National Health Service—and I know the Minister is a details man. I hope he will commit today to taking the measures needed to maintain trust, and that he is willing to agree with the proposition that a British Government, of any political colour, will have failed if the people of this country can no longer go to bed at night free from worries about where they will get healthcare when they need it.

Baroness Merron: My Lords, I start by thanking my noble friend Lord Hunt for his visionary introduction. We share the privilege of both being former Health Ministers and are therefore also fortunate to have the benefit of insight into how things can be, with the right approach by government.
My noble friend Lord Dubs spoke of the value of quality public services. As he was doing so, and while we were having such a passionate and intelligent debate, I was sorry to hear the sad news of the death of Alistair Darling, a giant of public service and former Member of your Lordships’ House. May his memory be for a blessing.
In the wake of the Second World War, the Labour Government founded the National Health Service through the leadership of Prime Minister Clement Attlee and Health Secretary Nye Bevan. While the values on which it was founded still survive, its ability to deliver on them, as we have heard today, has been greatly diminished by the biggest crisis in its history and by stagnation; while the world, the whole of our country and the expectations and demands of the people in it have changed around it, not least through the widening inequalities in healthy lives and access to healthcare that the right reverend Prelate the Bishop of London so clearly identified. The current situation is so dire that leaders at the King’s Fund, the Health Foundation and Nuffield Health felt a need to write on the 75th birthday of the National Health Service to the leaders of each major political party, urging change.
The content of their letter was stark and bears reflection. According to it, the NHS has insufficient resources to do its job, fewer beds than almost all similar countries’ services, equipment that is out of date and inadequate, buildings that are falling down, and inadequate IT systems to do the job. It does not have enough staff, so people’s needs are not being met, whether they are patients on the receiving end or staff seeking to do the job; and it does not matter how hard-working those staff are because they are struggling to deliver care of a quality that people need and deserve. As my noble friend Lord Prentis emphasised in speaking about the whole team, whether we are talking about the cleaner or the consultant, all play their part. The letter also said that any plans to move care from hospitals to closer to people’s homes have seen movement in the opposite direction only. All of this, while public satisfaction is at its lowest level in 25 years, with no let-up in sight.
This is the key question that I always think of when we discuss waiting lists and the other challenges for the health service: can the Minister explain to your Lordships’ House how the Government got us to this  stage? They have had 13 years in which to improve things; it is impossible to ignore the role of government—the role this Government have played since 2010.
Of course, I am sure the Minister will point to the pandemic. My noble friend Lord Brooke acknowledged, as I would, that it is clearly a factor. However, even prior to then, between September 2009 and September 2019, waiting lists almost doubled to 4.4 million. Now, that waiting list stands at 7.8 million, which is an all-time high. The waits are felt across the National Health Service. In A&E, nearly one in three people is waiting over four hours. Category 1 ambulance calls take almost two minutes longer than the seven minutes that they should, and the 62-day cancer treatment target has not been met since 2015.
Unsurprisingly, the failures are not limited to the most high-profile areas, as my noble friends Lady Taylor of Bolton, Lord Cashman, Lady Crawley and Lady Donaghy all referred to. To name just some, nearly 2 million people of all ages are waiting for mental health treatment, with about three-quarters of that number of people being out of work with mental illness just between January and March this year. The economic as well as the individual impacts of this failure are quite clear.
In ophthalmology, patients wait for surgery to address preventable sight loss, while patients are also being lost to follow-up with no route back to primary care if treatment has started. In social care, as highlighted by my noble friends Lord Dubs and Lady Pitkeathley among others, the autumn survey of the Association of Directors of Adult Social Services found that 250,000 people were waiting for an assessment of their needs, and almost the same number again were waiting for their care and support to begin or to be reviewed. What are the Government doing to address the lesser talked-about areas that still have real significance to people’s lives and well-being?
Returning to waiting lists, the Health Foundation believes that, by next summer, the list could be over 8 million. What is the Minister’s response to this prediction? Have the Government done their own modelling on the length of waiting lists? What responsibility do the Government take for the impact of their policies, and therefore what action will they take? In the spirit of co-operation that has been mentioned in this debate, perhaps I could offer a suggestion to the Minister, who is, of course, welcome, as he knows, to adopt any of the commitments that have been given by Labour. To take immediate action to cut these waiting lists, what about paying staff extra to provide the extra clinics and appointments that patients so desperately need? If this Government will not do it, if Labour is in government, we certainly will.
That is just about the immediate. As we have heard today, the UK’s population is undergoing a massive age shift. More than 11 million people over the age of 65 are living in the UK now, and in a decade this is expected to rise to some 22% of the population. As my noble friend Lady Pitkeathley said, it is to be celebrated that we have an ageing population. But, sadly, growing numbers of older people are experiencing poverty, discrimination and poor health in their advancing years. This, therefore, requires a reset, but primarily in  health and care, with a new focus on prevention and community care, driven by technological advances that we can take advantage of today—as my noble friend Lord Drayson highlighted.
Training more GPs, district nurses and health visitors, harnessing technology and AI, giving NHS and care workers fair pay and fair terms and conditions, joining up services and giving patients the choice that they want to help achieve these things: that is what a Labour Government would do. Why have this Government not done this?
The noble Baroness, Lady Finlay, and other noble Lords called for a change of focus from dealing with sickness to prevention. This is not only common sense; it makes economic sense too. Research by the Centre for Health Economics at the University of York found that spending through public health functions in local government is up to four times as cost effective as NHS spending—something my noble friend Lady Taylor of Stevenage brought her great wisdom to. The Government clearly know this, as their own 2019 Green Paper said:
“The 2020s will be the decade of proactive, predictive, and personalised prevention”—
but they simply have not followed through. As my noble friend Lord Davies highlighted, the failure to provide for the reform of the Mental Health Act—something that Labour has committed to doing if in government—is the clearest example of not following through. However, as we have heard today, there are many other examples.
At 75 years, the NHS, its workforce and all the people it serves deserve better. If this Government will not fix the crisis they have created and give the NHS the reform and support it needs, somebody else will have to do that. We stand ready to do so.

Lord Markham: I would like to start by giving our side’s condolences to the family of Alistair Darling. I echo the points on him made by the noble Baroness, Lady Merron. The noble Lord, Lord Brooke, talked about the cross-party working. Alistair Darling was one of those people who, while clearly a Labour politician, approached things in a very objective, cross-party manner. I know he will be missed by all of us.
I thank the noble Lord, Lord Hunt, for tabling this debate, which has been fascinating. It started off with a very informed and fascinating history of the NHS from my noble friend Lord Lexden, which enshrined the point that the noble Lord, Lord Allan, made: it has given us all that wonderful freedom to go to bed at night and feel secure, and to make life choices about where we work and who we live with without that being a worry. I agree with the basic premise that that is the duty of any Government.
I am also kind of—I am not quite finding the right words to say, but I was really marked by the point that the noble Lords, Lord Hunt and Lord Brooke, and the noble Baroness, Lady Pitkeathley, were at the 50th anniversary and took part in these conversations. That is quite humbling, particularly since I found out,  strangely enough, that I am currently the longest-serving Health Minister. I am not sure that I will make it to the 100th anniversary, but I will take the advice of the noble Lord, Lord Prentis, by trying not to walk in the middle of the road and get hit. If I do make the 100th, I will definitely follow the idea from the noble Lord, Lord Dubs, of having a party.
I welcome the debate. While I will try to answer the points raised, given the 75th anniversary, and as others have mentioned, it is important that we try to make this forward-looking and look at the innovation agenda, which the noble Lord, Lord Hunt, and the noble Baroness, Lady Taylor, mentioned.
I will also address squarely and up front the funding point, which was mentioned by the noble Baroness, Lady Crawley, and others. Rather than only putting a nickel into this, we are putting in 11% of GDP—by far the highest amount in history. Tony Blair has been mentioned a lot. I well remember the Wanless review in the early 2000s, which talked about increasing the spend to about 8%—my memory might not be quite right, but it was about 8% of GDP. I do not think that anyone would say today that 11% does not absolutely show our commitment.
It is comparable to all other European countries. In fact, there is only one country in the world which has a significantly higher spend: America. I want to put that record level of investment on the record. As many have mentioned, it is of course important that we allocate that and use those resources as well as possible. I was very struck by the points that the noble Baroness, Lady Tyler, made about the productivity conundrum, so to speak, and those that the noble Lord, Lord Drayson, made on the technology agenda and innovation. I hope to address some of those points a bit later.
I put all this into the context of our knowing today that a digitally mature trust will be 10% more efficient. We have done quite a bit of work on this; it will be 10% more efficient than other trusts in its output and efficiency. Since a few people mentioned the new hospitals plan, I should say that we know that a new hospital where you unite the best in technology with the best in physical real estate will be 20% more efficient in its output. That is not just in productivity; more importantly, probably, we are also seeing a 20% reduction in the length of stays. The one statistic that has impressed me the most, as I have gone around in the year or so that I have been in this job, is that for every week a patient spends in hospital they lose another 10% of their body mass if they are elderly, so their ability to go home—back to the normal environment—degrades day by day.
We have been talking about what we are trying to do with the technology agenda and the new hospitals programme, but we are all here because we care about patient care. That is vital. We all want people to get back into their home environment sooner. We all know that the problems often come when you are locked in for too long. Then you need a social care space and can get into the downward spiral that we all know about.
As someone actively involved in the new hospitals programme, I assure everyone that there are action steps happening on all 40 of those new hospitals. They  are all very real. I will happily talk to anyone about any of them if they should wish it, and show them my photos from visits to many of them as well.
The noble Baroness, Lady Donaghy, made a very good point: often, it is the short cycles which are hard. One thing that has not been spoken about very much, but was very much part of our new hospitals plan and the announcement in May, was our moving to five-year capital cycles. That will be really important for that long-term planning; work is going on as we speak around having 25-year to 30-year capital cycles.
I am trying to address the points raised. The noble Baroness, Lady Merron, understandably mentioned the waiting lists, as others did. Obviously, that is an area of concern but we have made good progress in the area of two years and are making good progress in the area of 78 weeks. We are focusing on those areas where there is the most impact. Undoubtedly, industrial action has impacted this, which is why I think we are all pleased that we now have a likely deal with the consultants. I am hopeful that it will extend to the junior doctors as well, but we have been working hard on that. We are trying to get on top of it: in terms of supply, there are the 130 CDCs with their 5 million tests. There is also the use of technology, such as patient choice with the app and the FDP, and we will see big improvements in what that does.
Through all this, we have been talking about the 13 years in which Conservatives have been in charge of the NHS in England. Of course, there have been 25 years that one party has been in control in Wales. I noticed that no mention has been made of Wales. While none of us is happy with the waiting lists, I know for sure that they are a lot better in England than in Wales.
I turn to the 62-day backlog for cancer. We all know that time is of the essence in cancer. We are seeing a 27% reduction in that backlog since 2020 and a record level of referrals; we are treating 12,000 people per day. We are starting to hit the 75% target of diagnosing people within 28 days. To put this into context, we are treating 32% more people for cancer than we were prior to the pandemic. We know that fast diagnosis is key.
One of the key differences in inequalities in life expectancy, as raised by the right reverend Prelate the Bishop of London, is lung cancer. Of the nine-year disparity, one year is caused by lung cancer. That is why we have things such as mobile screening, which we take on the road to areas where lung cancer is most prevalent—for example, in some of the mining communities. Rather than the majority of people with lung cancer not being found until stage 4, when it is too late, in the areas where they have been doing this we are finding the majority of people in stage 1 or 2. That is so much better in terms of life chances. That is how we will achieve the target of detecting 75% of cancers by stage 1 or 2 by 2028. To give some context to that, we estimate that it will mean that 55,000 more people will be surviving as a result by then.
There has also been talk about waiting times for ambulances and A&E. While they are too high, I am glad to say that they are improving. We have been making sure that we have learned lessons. We are  taking action for this winter by increasing supply, with 800 new ambulances, 5,000 more beds to increase capacity and the 10,000 virtual ward beds we will have in place. We are using technology, which I will come to later, to make sure that they are being most effectively used. We are making sure the hospitals are digitised. We have features such as those I saw in Maidstone, such as flight control, where you allow the clinicians to manage the flow of patients right the way through.
Key to all this and to the length of stay is discharge and the adult social care end. Quite rightly, as the noble Lord, Lord Prentis, said, the flow is important. It is vital not only on the social care side, but for the whole hospital and the UEC—urgent elective care—waiting lists. I have seen at first hand the impact of step-down areas. Patients can be put there early on, and everything is organised around that. I have seen the improvements that makes to the flow.
We are trying to learn the lessons of last year by getting the money and commitments out early. That is why we are making a commitment of £600 million extra spend. We told the local authorities and systems that in the summer, so they could plan now rather than hearing about it too late and not being able to impact it then. That is all part of an increase of up to £8.1 billion over the next two years—a 20% increase. Staff are at the centre of that, as mentioned by the noble Baroness, Lady Pitkeathley. It has been a difficult area, but we are now up in terms of staff versus last year. I accept that there is still a long way to go. My notes show that we have about a 15,000 increase in staff, but clearly, we need more within that.
Mental health is obviously a key part of this. As the noble Lord, Lord Davies, and others mentioned, now more than ever we are seeing a massive increase in the number of young people with mental health issues—we had a good debate on this the other day. As I have said, I am determined that we understand the reasons underneath that. Covid might be part of it, but there are also long-term reasons, such as social media, that we need to understand. As the noble Lord, Lord Davies, mentioned, we need to make sure we diagnose those early, because that is crucial, particularly for young children. As noble Lords know, I have personal experience of the importance of acting early on this.
On the mental health Bill, we are committed, as mentioned, to do as much as we can without the legislation—hopefully we can explain a lot of that when we have the round table. Although getting it in the manifesto might be above my pay grade, I personally agree to make sure that all my colleagues understand its importance today and in a year’s time or so, if we were to win a general election.
Many noble Lords—the noble Baroness, Lady Tyler, and the noble Lords, Lord Prentis and Lord Hunt, to mention a few—raised the importance of staffing and how everything is underpinned by it. The noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt, in particular picked out—and I completely agree with them—that it is not just the clinicians but the managers, the admin and the non-clinical staff who are key to this as well.
I am a bit of a data anorak, and one of the things I did when I first came into my post was to try to understand all the differences in hospital performance, looking at certain areas’ demographics and whether they happened to have more funding through a quirk of the formula. I put in all sorts of variables, but we could only ever explain 50% of it—for the data anoraks, I say: the r² never came out higher than 0.5. The only conclusion that I and others could come to from that was—this is not earth shattering—the management and the leadership. I have had the privilege of visiting a lot of hospitals, and when you walk into one you know early on about the leadership—you can tell it on the tour and through the reaction, less from the leaders and more from the staff. You get a vibe about a place. I totally agree about the importance of that.
I come to the specialist areas. The noble Baroness, Lady Taylor, mentioned optometrists, and, funnily enough, I had this conversation with one the other day, and they mentioned that many of the early, indicating warnings are picked up when they take retina scans. That is why the long-term workforce plan is important, as are the extra training places. But, as the noble Lord, Lord Prentis, said and as I know from my experience with my mother, the other routes, such as apprenticeships, are just as important if we are going to get them there, because you should not need to be a graduate to be a nurse or clinician. As the noble Baroness, Lady Finlay, mentioned, it is vital that it is a rewarding and accommodating profession. Training and development are obviously part of that. I hope to talk more to noble Lords soon about using the estates for a lot more housing, because we know that can be a key recruitment and retention tool. Then there are things such as flexible rotas—hopefully, we will be able to use technology for that.
In terms of talking and working with the staff, I have to say that is something that is early days, but we are seeing the style and the engagement of the Secretary of State already and it is very welcome. Underpinning the long-term workforce plan, which many noble Lords have mentioned, is the move away from hospital treatment and into primary care and prevention. We know that that is the first line, and we are now close to achieving the 50 million increase in appointments—but we know, given the demand, that that is still not enough. That is where the Pharmacy First scheme will make a material difference, in expanding the supply of places where you can get the advice and treatments that you need.
I have seen some great examples of prevention, also mentioned by the noble Baroness, Lady Pitkeathley. Funnily enough, just yesterday I was talking to one of the doctors—I am sure that many of you know him—Sam Everington from east London. He was talking about how he was taking type 2 diabetes treatment totally out of the hospital environment, and the difference that it is making there. I have mentioned before the Redhill frequent flyers, looking at the people who are having the most hospital treatments and how they can get upstream of it all. Screening is important to that, which is exactly the point that the noble Lord, Lord Cashman, was making about the HIV screening programme. That needs to be welcomed—making sure that many more people are seeing that and understanding it.
The noble Baroness, Lady Taylor, talked about an active and healthy lifestyle and its role in social prescribing, which I completely agree with. I know that all noble Lords are on the same page here. The anti-smoking legislation that we are talking about is the biggest single thing that we can do towards that active lifestyle going forward.
I have mentioned it a few times, but I really believe that what we do in terms of technology and the app will be key to this, in terms of people’s access to primary care. People can use the app as their front door, from which they will be guided to the right service—to the 111 service—and then directly make an appointment, be it with a doctor or nurse or with a pharmacy. We have seen already that because people are reminded on the app, the numbers of “do not attend” have gone down by 10%, when people make their appointments digitally in that way. Of course, that means a much more effective use of time. Talking of time, I notice that I am out of it, so I shall quickly finish up. I see massive ability in the app for people to take control of their health and give us that sort of data, so people have the information and trust behind it.
I could have written the speech made by the noble Lord, Lord Drayson, myself—and I quickly acknowledge everything that he said about the problem. He said that we have great examples of innovation and really difficult cases of how to scale that up. I am exaggerating slightly to make a point, but when they have a great example in one place, they say, “Fantastic, it works in X hospital, how can we get it elsewhere?” It is like, “Here’s the telephone directory with 140 trusts and the buyers—good luck”. A lot of what I am trying to do, as the noble Lord, Lord Drayson, mentioned, is to look at how we scale that up, and have a way to buy sensibly from the centre and get that spread out. In the area of digital therapeutics, that is obviously vital.
Given the time, it is probably time for me to sum up, as I say. As ever, I shall write to noble Lords in detail. I have not answered the points that the noble Lord, Lord Cashman, raised about international cosmetic operations, and others. Likewise, I have not addressed the fracture liaison services, and the points made by the noble Baroness, Lady Donaghy, and the noble Lord, Lord Lexden, so I shall make sure that that is properly followed up in writing.
I finish by echoing what the noble Lord, Lord Brooke, was saying, which is to try to take this out of the Punch and Judy and make it as cross-party as possible—

Lord Hunt of Kings Heath: My Lords, does the Minister understand that I will have no time at all to respond?

Lord Markham: I apologise: I will sit down this moment.

Lord Hunt of Kings Heath: I have only a minute now to respond: I understand that the clerk will time us out at 2.56 pm.
All I will say then is, first, that I thank the Minister and my noble friend Lady Merron for their tributes to Alistair Darling, who was such a formidable colleague, Minister and public servant.
Secondly, the conclusion I reach is that we have to have a whole-system reform; we need a Government who are determined to do it; I do not believe that the current Government can do it at all; I look forward to a Labour Government who are going to do the business; and I beg to move.
Motion agreed.

Benefit Claimants: Free Prescriptions
 - Question for Short Debate

Bishop of London: To ask His Majesty’s Government what impact the removal of free prescriptions for benefit claimants who fail to look for work will have on their health, and the health of the workforce.

Bishop of London: My Lords, I start by thanking your Lordships’ House for giving time for this important debate. I also thank the House of Lords Library for its very helpful briefing and the Minister for his engagement with me and for our helpful meeting earlier this week about this debate.
The measures we are discussing today relate to the announcement that the Government made in the Back to Work Plan and the Autumn Statement that people on universal credit who do not engage in activities designed to increase their skills and improve their employability after 18 months of support will have their claim terminated. With that termination, their accompanying passported benefits, including free prescriptions, will also be stopped.
Benefit claimants may disengage from Jobcentre Plus for many reasons, some of which I suspect we do not completely understand, and not solely because they have failed to look for work. I have brought this debate forward from a health perspective, and the central frame of my remarks today is around health inequalities, because the Back to Work Plan as it stands could serve to exacerbate these inequalities. There are many complexities within universal credit, and many exemptions and allowances that are made for vulnerabilities and medical conditions that are to be commended. I was grateful to hear about some of them at the meeting I had earlier in the week with the Minister and officials from DWP and DHSC. I understand that the number of people who will be affected by this is small: they are those without a vulnerability that would exempt them from having their claim ended, and who do not have an additional factor attached to their claim.
However, I also understand that those who will face this measure will have already been zero-rated for six months, for which time their prescription fee exemption will have already been removed. I believe the mitigation there is that if they have a health condition, they can access low-level prescriptions, such as an asthma pump, until the time their claim is stopped. I know that these mitigations and allowances are designed to reassure those of us scrutinising these plans and, more importantly, those who are fearful of losing the prescriptions they need. I appreciate that this measure will impact only a  small number of people, whose prescriptions are likely to be of a low level, but I have some significant concerns.
First, as this House is acutely aware, we are in a cost of living crisis. The Royal Pharmaceutical Society published the results of a survey of pharmacists earlier this year. Some 51% had experienced an increase in the number of patients not collecting their prescriptions in the six months before the survey, and 52% reported an increase in patients asking for different items to be prioritised due to affordability concerns. Some 67% had seen more patients asking about cheaper, over the counter alternatives to their prescriptions. If prescriptions that were once free are no longer so, a person whose universal credit has just been stopped may not be able to afford their prescriptions. This is a serious concern, especially when in so many other ways the cost of living crisis has been an incubator of the gaping inequalities that remain.
Secondly, it is those who are unable to engage with Jobcentre Plus who are most likely to be subject to poor conditions that determine their health, or ill health. It is these people who are most likely to make up the “plus” of the Core20PLUS5. It is important that all engagement with them is not lost when their claim ends. If they struggle to engage with public services, any poor health they experience may worsen if they do not take the medication prescribed. Even if the prescription is of a low level, these prescriptions are fundamental to keeping us in good health, and our being in good health will in turn relieve pressure on the NHS. An acute asthma attack in A&E costs far more to the public purse than someone’s routine inhaler and has a far more profound impact on the person concerned.
I would be very interested to hear from the Minister how the department is working to understand the reasons for people’s disengagement from the support it offers, and what resource there might be for the department to offer the steadier relational support that I know Jobcentre Plus hopes to offer. Have they considered a way to identify those who are extremely vulnerable, and work with the health services to ensure that they do not fall off the radar, perhaps by informing the GP that their claim has ended?
Thirdly, I appreciate that this measure is a deterrent from disengagement and is designed to act as an encouragement into work. I was unaware, until meeting the Minister this week, that parliamentary legislation will be required to bring forward these changes. I have no objection to that in principle, but I am concerned that, with a limited amount of parliamentary time, there is a risk that this legislation will never appear. I am concerned that this proposed measure and the press coverage, which I acknowledge was not completely accurate or helpful, seems designed solely to deter, causing anxiety and fear. This is concerning, even given the small number of people it will impact, and when we are dealing with changes to a highly complex system, it often increases anxiety. To use, or to threaten to use, health measures in any way as a punitive consequence for disengagement is, I believe, a misuse of power and could have a significant impact on the lives of people who need to be helped, not punished.  Can the Minister confirm exactly what is needed to be brought in by primary legislation—whether it is the whole Back to Work plan—and share whether he has any expectation of when it might progress?
The expansion of the health programmes within the Back to Work plan are welcome and I know that they have been commended as part of the Autumn Statement debate. Health and work are linked, and prioritising the health of the workforce is required for a thriving economy. Part of that is to ensure that people have the option to take time off if they need it, which under the current sick pay system may not always be possible. This is especially true for those in insecure work. A report by WPI Economics, Making Statutory Sick Pay Work, highlights stories of workers coming back to work while still sick or injured because they cannot afford to take time off. Can the Minister say whether the Government have any plans to examine statutory sick pay and ensure that those who are working have the option to take time off while they are ill?
On a slightly different note, I was very surprised to read in the Lords Library briefing that the total cost to the NHS of exempt prescription charges from community pharmacies in England was £9.9 billion, while paid-for prescriptions made up only £500 million. It makes me wonder whether installing universal free prescriptions would be less costly than is sometimes assumed and whether the savings to the public purse from better public health may well be worth it.
I again thank the Minister and look forward to hearing the speeches of noble Lords participating. Worsening health inequalities is one of the worst health outcomes of recent times and it requires a multifaceted approach. It is important to consider how people’s health may be impacted by measures that are not directly health based, and I feel encouraged that the Chamber has decided to debate this.

Lord Davies of Brixton: My Lords, I thank the right reverend Prelate the Bishop of London for securing this debate on the end of free prescriptions for certain benefit claimants. She covered, in detail, the operational effectiveness of this and how it works out in practice; I will talk about the philosophy that lies behind the proposal.
As I said in yesterday’s debate on the Autumn Statement, I am angry. I saved my anger from yesterday’s debate for today. It is unfortunate that the noble Viscount the Minister, for whom I have considerable respect, has to be the butt of my anger, but my anger exists nevertheless. I am angry about this cruel and outrageous proposal that reflects so badly on a Government that have already lost much credibility and honour—I am angry and sick to my stomach. My immediate reaction when I read this policy was to ask, “Are we back to the workhouse?”. I am angry, because we have known for almost two centuries that the policy of less eligibility simply does not work—not only does it not work; it leads to further cruelty in a race to the bottom, devoid of compassion and sense.
I will talk history. I am sorry that we have lost the noble Lord, Lord Lexden, who gave us a history lesson in the previous debate today, for which three of  us were present—but here is some more history. I will talk about the Poor Law and the principle of less eligibility that played significant roles in shaping the approach to poverty and welfare in the 19th century, particularly in the United Kingdom.
The Poor Law, a system of social welfare that dated back to the 16th century, underwent significant reforms in the 1830s with the implementation of the Poor Law Amendment Act 1834. The core principle of the Poor Law was the provision of relief to the poor through workhouses, which were intended to be austere institutions to discourage dependence on state assistance. The workhouse system aimed to make poverty less desirable than the lowest paying jobs available, thus enforcing a concept of less eligibility. That meant that conditions in the workhouse were intentionally made to be harsher than the worst situations outside, creating a deterrent against seeking public assistance.
Less eligibility sought to create a clear distinction between the deserving and the undeserving poor, with the belief that the fear of destitution would drive people to seek alternative means of support. The workhouse environment was designed to be Spartan and unpleasant, reinforcing the idea that dependence on state support should be a last resort.
It became clear, however, that the Poor Law and less eligibility meant the system was dehumanising and punitive, pushing vulnerable individuals and families to the brink of despair. The workhouse conditions were often harsh, further exacerbating the emotional toll on those seeking assistance. Charles Dickens, through his literary work such as Oliver Twist, on the Poor Law and its bastard children, vividly depicted the hardships faced by the poor in workhouses, contributing to public awareness and debate. Over time, society’s attitudes shifted and the harshness of the Poor Law system began to be questioned. As the 19th century progressed, there were calls for reform and a more compassionate approach to poverty. Eventually, the Poor Law system was largely dismantled in the early 20th century, making way for the development of modern welfare programmes.
In retrospect, the Poor Law and less eligibility reflected the prevailing ideologies of the time, attempting to address poverty through deterrence rather than systemic support. The approach was rooted in a belief in self-sufficiency, but it ultimately led to widespread suffering and hardship for those already marginalised by poverty. The lessons learned from the shortcomings of the Poor Law should influence contemporary discussions on social welfare and the importance of a compassionate and inclusive approach to addressing poverty and inequality. However, it is as if the Government have forgotten these lessons.
My question to the Minister is: has he read his Dickens? Does he realise that, not as an individual but as the representative of the Government here today, he is playing the part of the villain in an up-to-date Dickens novel and that he is, in his official role, if not personally, acting as a modern-day Mr Bumble, the cruel manager of the workhouse in Oliver Twist, devoid of compassion? I was struck by the remarks of the noble Baroness, Lady Vere, in the discussions yesterday, when she claimed that this was a compassionate policy. I think it is identical to Mr Bumble, the cruel manager claiming to be compassionate.
When we look at the people who will be affected by this policy, we do not really know much about their characteristics—I think that was the point that was made—so we do not know who will be harmed by this policy. Make no mistake: the intention of this policy is to harm people. I suspect that few if any people fit the tabloid caricature of the feckless, workshy scrounger, but we do know that these people are poor. We also know that they are ill, and we know this policy is designed to make them poorer and iller. To put it at its clearest, even the feckless, workshy scrounger deserves the medical treatment they require.
I hope the Minister can hear history speaking to him, saying that this policy is a component of the failed idea of less eligibility, and it is bound to fail and create more problems than it seeks to address.

Baroness Bennett of Manor Castle: My Lords, it is a great pleasure to follow the powerful speech of the noble Lord, Lord Davies of Brixton, who has reminded us of how in many ways our society is going back to Victorian times with the level of inequality and the insecurity affecting so many people’s lives. In the times the noble Lord was talking about, the spectre of the debtors’ prison hung over so many families. We are potentially back in that situation now, except that of course the spectre now is of benefit sanctions, which hit so many people utterly unjustifiably.
As the noble Lord said, poverty is a feature of our system, not an individual failing. I thank the right reverend Prelate for securing this terribly important debate. It is a grave pity that we do not see on the speakers list any Tory Back-Benchers stepping up to defend the policy—although I note that one noble Baroness on the Tory Benches has joined us to listen to the debate. Perhaps the others will read it in Hansard later.
The right reverend Prelate talked about “significant concerns”, in the manner of her speeches. I would go much stronger: this is a disgusting piece of dog-whistle politics targeting the most vulnerable in our society and, as the right reverend Prelate said, possibly having minimal effect in saving the Government money and likely costing them money, while spreading fear in an attempt to activate some of the least desirable emotions in our society.
I am going to take a somewhat different approach from the noble Lord, Lord Davies, and look at the medical impact. The right reverend Prelate clearly and cleverly set out the debate by talking about the impact on individual health and the health of the workforce, so my speech will cover those two areas. I looked in some detail at to whom free subscriptions are available. There is a group of conditions—cancer, diabetes, hypothyroidism and epilepsy are among them—the sufferers of which automatically have the right to free prescriptions. I ask the Minister to put on the record that, if you have those conditions, even if you are affected by these rules, you will still get your cancer drugs and diabetes drugs. It is incredibly important to put that on the record for people to understand.
Let us think about some of the conditions that are not included in what I hope is an automatic exemption from prescription charges. Mental health conditions  are not on that list. As the right reverend Prelate highlighted, asthma medications are not on that list. Of course, free prescriptions for everybody would be the ideal situation for our society, for the health of both individuals and the workforce—and I point out that that is Green Party policy and where the NHS started. Another group of drugs taken by huge numbers of people, particularly older members of society, is statins, which treat high levels of cholesterol that can lead to cardiovascular disease, heart attacks, coronary heart disease, angina and stroke. Can the Minister confirm that statins, asthma medication and drug treatments for mental health conditions will all be covered by these sanctions? More than that, what about counselling? Will the NHS continue to provide counselling to people who need it if they are affected by these sanctions? I am not sure I have seen that explained.
I want to put this in a broader context—and it is a great pity that none of the House’s legal experts is taking part in this debate. In the World Health Organization’s constitution, to which we are of course signed up as a member, the
“highest attainable standard of health”
is a fundamental right of every human being. More than that, I hope the Minister will acknowledge that the right to life is a fundamental human right. If we are going to deny people statins, asthma drugs and mental health treatments, how does that square with the basic right to life, let alone the best attainable standard of healthcare, which we are signed up to through the WHO?
I turn to a broader question, on which the Minister might agree with me a little. Your Lordships’ House may be aware that yesterday, under a new methodology, a survey by the Office for National Statistics suggested that the current unemployment rate is actually 3.5%. We have a labour market in which the essential problem is a shortage of medical professionals, care workers, HGV drivers and construction workers. We need to start to think about human time, energy and talents—scarce resources that need to be nurtured, cultivated and looked after. We will be having a debate later on early years, in which I will be participating. We need to give people the best possible start in life, so they can contribute best to our society.
The right reverend Prelate hinted at this: the best way we can look after people and ensure that they are fit to contribute to our society—it might be through paid work, voluntary work or caring for family members—is to offer security, which is what people need in all those situations. This is why the Green Party’s alternative Autumn Statement said, “Let’s lift the basic level of universal credit payment by £40 a week”. I put it to the Minister that giving people unconditional payments—indeed, the Green Party’s aspiration is for a universal basic income—and a universal, secure payment that meets their needs means that they can be healthy and can contribute to society through paid work and other means. We would all be richer. Making people ill and forcing them into impossible situations, even fear, is a huge problem.
I circle back to the point I started with—the noble Lord, Lord Davies, also mentioned it—concerning Victorian times. Too often, poor health is seen as an individual characteristic, yet we have a deeply unhealthy society. We have terrible levels of air pollution on our streets and in our homes. We have terrible-quality homes with poor insulation, people cannot afford to heat their homes and there the problem of mould, which has been illustrated so tragically lately. To get a healthier and more productive society, as well as the kind of growth the Government are so keen on, the best thing to do is ensure that we have free prescriptions and free support for everyone who needs it. This would help everyone to contribute to our society as best as they can, rather than punitive sanctions waved at some of the most vulnerable people in our communities.

Lord Allan of Hallam: My Lords, the right reverend Prelate the Bishop of London helpfully said in her opening speech that she was in some ways surprised to see that this issue would require legislation. I fear that may actually be the point: that the whole purpose of this is to table something and invite Members on this side of the House to vote against it, so that the Government can somehow claim that we are being weak on the workshy. I must say, whenever the Government find time for something such as this—as noble Lords might expect, I think it is wrong in principle and in practice—in lieu of other legislation we have called for, such as on mental health, we have to question their priorities and whether all we are seeing now is a political agenda from a party playing out its last few months in office.
I turn to the substantive issue and why I think this is wrong in principle and in practice. On the principle, we need to understand the rationale for prescription charges. We are not paying for our drugs when we pay prescription charges; the rationale is that people who can afford to do so should make a contribution to the costs of operating the entire system of dispensing prescriptions. Those people are working-age people, in work. The whole system is based on that rationale. People who are not of working age do not pay prescription charges: 70 year-old millionaires—and, indeed, their 15 year-old children—do not pay them. The whole system is based on this, so taking a segment of people who are, by definition, not in work and magically putting them in the in-work paying bucket is entirely inconsistent with the whole scheme as it has been set up.
No deserving/undeserving judgment is made with prescription charges; otherwise, we would be testing people’s incomes and whether they had made themselves ill before getting a prescription. We do not do that because that is not the rationale. The rationale is that people who are in work and have the means to pay, such as myself, should do so. I do not speak for others, although I would have spoken for the noble Lord, Lord Markham, had he been here, because he is in a similar position, in that we are the kind of people who should be paying prescription charges. In a few years, I will stop because I will be deemed no longer of  working age, so, although I will have plenty more time here, my prescription charges will cease. Being in work and being of working age are the criteria for making contributions.
In principle, we are breaking that and I see no rationale for doing so. Saying that you have not complied with a jobcentre request and therefore you lose access to the scheme is so inconsistent with everything else that has been set up. That is particularly the case where an obvious response to the sanction is that someone should seek the healthcare they need. Everything in the prescription contribution system has been carefully designed not to deter people from getting drugs. A whole bunch of exemptions are wrapped around this to do that. To undermine it seems entirely problematic.
I turn to the practical issues. The prescription charges are not a fee for the medicines. They are completely unrelated to the cost of the medicines; they are a contribution to the NHS. They are capped at £111.60 per year and the cap is set, effectively, by the prescription prepayment certificate. Anyone who needs more prescriptions than would add up to that price is entitled, whoever they are, to get a PPC. I assume that this will apply equally to the cohort we are talking about today. If the claimant has a condition that needs several prescriptions per year, we are effectively fining them £111.60 per year. This is probably one for the Minister’s DHSC colleagues but, given that we have set a cap, I am curious why, if TfL can figure out when I have travelled enough during a day to hit its daily transport cap, the prescription pricing system—which is all computerised—cannot figure out when I have hit the £111.60 cap and automatically apply it. The obvious reason is that it is hoped that people will keep paying beyond the cap. If we are to have a cap, let us help people claim within it rather than send them over it. That is particularly true here.
This £111.60 fine is now being levied as a sanction on top of all the other sanctions for this group of claimants. The first option is to pay the fine so that, if you need the medicines, you can go off and get them. The second is to keep ticking the exemption box. All sorts of people do this all the time. You run the risk of getting a £100 fine plus the cost of the prescription penalty charge notice at some point in future. Again, I am not saying that to invite it. It is a very common phenomenon. It happens all the time, so much so that the Public Accounts Committee down the other end has done a report on it, which was very critical of this whole system. It is quite expensive to administer and we spend a lot of time chasing people around for this. A rational response of someone in this category is: “Okay, here’s my choice: £111.60 or take my chances. Maybe I will end up paying about the same amount as and when they come and get me with one of these penalty charge notices”.
The third option is for them to stop taking the drugs that they need. That is the worst option, disastrous for all possible outcomes. I am looking at the noble Viscount the Minister—from the point of view of the benefits system, what possible interest is there in having someone stop taking their drugs if the goal is to get them back to work? I cannot see any circumstance in which someone who needs the medicine for a physical or mental health problem would be more fit for work  if they stopped taking the drugs than if they continued taking them. Therefore, I assume the hope is that everyone will pay the fine and treat it as just another financial sanction.
On the point made by the noble Lord, Lord Davies, the reality is that we have seen this lots of times in previous economic cycles. When there is a serious downturn in the economy, significant numbers of people—this will vary geographically according to where the downturn hits hardest—will move first to out-of-work benefits and then to sickness benefits. I was brought up in a posh bit of Sheffield but when my communities in South Yorkshire lost the steel and then the coal in the 1970s and 1980s, you saw entire communities moving from work to sickness benefit. What they had really lost was hope. Hope had gone and the community was devastated. People were sick in the sense that they felt terrible. That expressed itself in all sorts of physical and mental problems and they moved on to sickness benefit.
If you are in one of those communities, the solution is not fining you £111.60. That will not give you back your hope or encourage you to go out and take a job. I really fail to understand why the Government think it will. We have seen this play out before—it is politics. The Government must be seen to be doing something; they are trying to artificially create some kind of conflict where they are tough on the work-shy and people who question this are somehow championing them. I think this is completely the wrong target. I know politics must react to things, but in this case it is reacting incredibly clumsily.
I am very grateful to the right reverend Prelate for the opportunity to debate this issue. I leave the Minister with the following questions. First, have the Government assessed how affected people will split into those three categories? In category one, they pay their £111.60 for a prepayment certificate; in category two, they keep ticking the exemption box and risk a fine; in category three, they stop taking the drugs. For a policy of this significance, we need to understand—I assume the Government have some data as they are proposing this—how those people will split. If the numbers in category three are significant, that is the most important area of concern. Secondly, have the Government made any assessment of this measure versus a financial sanction of the same value? If the intention is to fine people for not going back to work, have they considered a straight cash fine rather than this clumsy prepayment certificate method? Thirdly, what measures will the Government take to make people aware of the prepayment certificate option, particularly if they move ahead with this? I hope they will tell everyone not to keep paying the individual prescriptions and to get a certificate as the cheapest option.

Baroness Sherlock: My Lords, I thank all noble Lords for their contributions to this short debate, especially the right reverend Prelate the Bishop of London for making it possible and for her introduction. I remain grateful for her continued commitment to the health and well-being of the nation, especially the most vulnerable within it, and I thank her for all she does in this respect.
Before I speak on the Motion, I would like to record my sadness at the news that Lord Darling has died. Before becoming a valued Member of this House, he was Chancellor during the global financial crash. The country was fortunate to be in the hands of someone of such ability and integrity. But as this is a DWP debate, he was also a fine DWP Secretary of State, with whom I had the privilege of working when I was a special adviser to Gordon Brown. Our country is the poorer for his passing.
As we have heard, the trigger for this debate is the Government’s proposal to close the universal credit claims of some people who fail to meet employment-related requirements. As a result, they would cease to have access to passported benefits, including free prescriptions. The noble Lord, Lord Allan, explained the rationale for a prescription charging policy, but the problem is that this is not a health policy. It is a policy that would try to use access to healthcare as a tool to enforce conditionality in the welfare state. The right reverend Prelate the Bishop of London has highlighted some of the real challenges of such an approach. As she, the noble Baroness, Lady Bennett, and others, have said, this clearly risks putting the health of some individuals at risk. It will clearly not make them any more likely to work—less likely, if anything—and it will probably end up costing the NHS more in the long run, as the right reverend Prelate’s example of asthma inhalers versus asthma attack treatment has shown.
The noble Lord, Lord Allan, is on to something on the point of this policy. I am sorry to say that I think there is an attempt to create dividing lines and say, “You do not really want to do X”. To avoid jumping into that trap, I will say for the record that we believe everyone who can work, should work. That has been the basis of Labour’s policy in the past and will be again. The welfare state was created to support those who could not support themselves, and conditionality has been part of it from the start. If people refuse to engage with the system, there must of course be consequences, but not like this. The quid pro quo is that the state should provide the help people need to get into proper, sustainable jobs, and I have real questions about how well it is doing that right now. Although that is a problem, I do not think anyone really believes that this proposal is the solution, and I think Ministers know that.
The OBR forecasts, after taking account of the Government’s plans, suggest that the employment rate will remain static, there will be 600,000 more people on sickness and disability benefits and that that will put spending up 75%. That does not sound like a plan that is likely to be effective in addressing its ostensible objective. It is hard to understand what the Government want to do with this.
In opening, the right reverend Prelate the Bishop of London said that, in her conversations with the Minister, she realised that very few people would be affected and that the media may have misreported this. To be fair, I think they were meant to report it in the way they had. I would not expect the right reverend Prelate to engage in the politics, but I simply quote from the speech made to the Conservative Party conference by the Chancellor of the Exchequer Jeremy Hunt. He said:
“It isn’t fair that someone who refuses to look seriously for a job gets the same as someone trying their best”.
It was then briefed out that the intention was to signal this as a crackdown on those who do not try very hard. The job of the Minister, for whom we all have great respect, is to say that this is one of two things: it is either a major crackdown, which potentially risks the health of many people, or it does not make much difference. I would like to know which it is, so could the Minister explain that?
The most obvious question is how many people will be affected. Has the DWP done a formal assessment of that? If so, please could the Minister share it? If it has not, why not? Secondly, as my noble friend Lord Davies asked, do we know which people will be affected? Are they young or old? Do they have children? Could they be single parents or carers? Who are they? Free prescriptions are just one of the benefits passported from universal credit. Others include dental treatment, help with travel to hospital to get NHS treatment, free school meals for kids and Sure Start maternity grants. Are those included in the same policy?
The right reverend Prelate mentioned that the Minister had indicated that most of these people will be on a nil universal credit payment and therefore would not qualify anyway. Either nobody in this position would be affected or some will be. What is the process to distinguish between them? Will that action be automatic, will a case be closed at a certain point, or will an individual assessment be made? What safeguards will be put in place to check whether people were failing to engage because of health problems, whether physical or mental? Will this need extra staff and, if so, what will that cost?
I cannot help but conclude that this policy is born of failure. Britain remains the only country in the G7 where the employment rate is still not back to pre-pandemic levels. Some 2.6 million people are now shut out of work due to long-term sickness—the highest number since records began. It is hard not to conclude that a major contributory factor is that the Government have let the NHS lurch from crisis to crisis, when waiting lists have soared to 7.8 million. More and more people over 50 are out of work due to long-term sickness. We all know that large numbers are stranded on NHS waiting lists, who are desperate for treatment or in pain. Many of those are mothers caring for older relatives or other people who are sick or disabled, and they are getting precious little help from the social care system, which still goes unreformed, despite 13 years of promises.
The right reverend Prelate said that health and work are linked, and she is absolutely right. It is quite right that health and employment policies need to be considered together, especially when we have these inactivity rates, but we need to do this in a positive, strategic way. Labour has said that we would invest £1.1 billion in the NHS to provide more appointments and get the backlog down. We would recruit 8,500 more mental health staff. We would also overhaul jobcentres, so that they can provide personalised help and work in partnership with the NHS, employers and others that can help people back into proper, well-paid, sustainable jobs. We would create technical excellence colleges, so  that people get the skills that would help them get jobs in their area and then bring the skills that are needed into those areas.
That is the way forward—not a policy that grabs a few headlines but probably will not make much difference anyway. We want a proper, strategic approach to the labour market, working with the health service to help get our country back to work. The social security system is there to support those who cannot work and to help those who can work get back into work. Does the Minister not agree?

Viscount Younger of Leckie: My Lords, I begin by expressing my own condolences at the loss of the noble Lord, Lord Darling. I was shocked and greatly saddened when I heard the news earlier today. He was a giant of a man, and he was extremely helpful, indeed instrumental, in helping the country through the financial crisis back in 2008 and onwards.
It is a pleasure to close this important debate which, at its heart, is about ensuring that more people who can work are supported to do so and benefit from all the rewards of work. I start by thanking all noble Lords for their valuable contributions, in particular the right reverend Prelate the Bishop of London for initiating this debate. I also thank her for our meeting earlier this week, which was greatly appreciated. Getting into work and ensuring that work pays remains a key government priority. Building on the £7 billion employment package announced in the Spring Budget, the Autumn Statement set out a further £2.5 billion investment in employment support over the next five years. This support will ensure that no claimant reaches 18 months of unemployment if they have taken every reasonable step to comply with the jobcentre support offered to them.
I will cover two or three points upfront. I was interested in the very hard-hitting speeches from the noble Lord, Lord Davies of Brixton, and the noble Baroness, Lady Bennett. They both opined about the issues of sanctions more broadly. It is fair to say that the right reverend Prelate the Bishop of London alluded to some misrepresentation in the press. I can think only that the noble Lord and noble Baroness have maybe been reading too much in the papers, but their questions were fair.
I say at the outset that conditionality supported by sanctions has been a long-standing feature of benefit entitlement and a policy of past Governments, including past Labour Governments. Claimants on work-related benefits are generally expected to take responsibility for meeting the conditionality requirements that they have agreed to with their work coach. Where a claimant fails to attend a mandatory appointment or fails to comply with specific work-related activities without good reason, an open-ended sanction is applied. Open-ended sanctions are applied from the date of the failure up until the date that the claimant complies with the agreed requirement—I will say more about this later. I am grateful to the noble Baroness, Lady Sherlock, for her general acknowledgment of this policy.
The right reverend Prelate the Bishop of London understandably asked about continued disengagement and whether the policies we are taking forward are a bit harsh—I think that is the general principle of what she said. Perhaps I can be helpful by saying that claimants are set mandatory work-related requirements based on the benefit regime that they are in. All mandatory requirements are tailored to the claimant’s circumstances and are discussed with them beforehand, as are the consequences of failing to comply. We have also hugely increased the training that job coaches have. I reassure the House that the quality of job coaches is increasing the whole time, and there is a great deal of sensitivity involved, as the House will imagine.
Following a failure to comply, the claimant has the opportunity to provide good reason. Additionally, a pre-referral quality check is in place to check for known vulnerabilities before a sanction referral is made. Following a referral, cases are reviewed to ensure that the mandatory requirement was fairly set in the first place and to check whether a conditionality easement should have been applied. Claimants will be contacted through the normal channels from the point of sanction decision. These include a digital nudge at six weeks following the decision. Where a claimant remains disengaged following an open-ended sanction, they will receive a notification at month five that will inform them of the claimant closure intention and prompt them to re-engage or to inform us of any new circumstances that may impact this.
The right reverend Prelate asked, reasonably, about the cost of living. We remain very aware of the pressures that people are facing with the cost of living. That is why we have provided £94 billion of support across last year and this year, 2023-24, to help households and individuals with the rising cost of bills. In addition, subject to parliamentary approval, working-age benefits will rise by 6.7% from April 2024, in line with inflation. The House is well aware of the Autumn Statement announcement on the local housing allowance rates, which I know will make a considerable difference.
The right reverend Prelate asked about statutory sick pay. There is a very short answer: we will absolutely continue to keep it under review. She also asked about primary legislation and timing. Although I cannot give her any precise information on the timing, I can say that it is very unlikely that we will be able to bring this forward during this Parliament. That helps perhaps to answer a question from the noble Lord, Lord Allan of Hallam.
Turning to the issue of disengagement, I should explain that for the quarter ending August 2023, 95.3% of sanctions were for universal credit claimants failing to attend a mandatory appointment with their work coach, as opposed to refusing a job interview. These sanctions are typically open-ended, as mentioned earlier, meaning that they can easily be ended at any time by the claimant re-engaging with their work coach. We know that the majority of people who have open-ended sanctions do re-engage with the support on offer within six months. However, there is still a growing number who are choosing not to engage with employment support, despite support being available to them.
It is important to place this area in the context of the Government’s wider Back to Work plan. A key part of this is about ensuring that a short spell out of work does not turn into a period of longer-term unemployment. I am sure that we all agree with that, because the longer someone remains unemployed, the harder it is for them to return to the labour market. This can have detrimental impacts on the individual, as well as the wider economy. That is why, as part of our plan, we are bringing in much more intensive back to work support earlier on in someone’s claim. This includes upskilling, job search support, practical work experience and tailored advice to support claimants. Those claimants who remain unemployed after 18 months of intensive support will undergo a review by a work coach and will be expected to either take up a job or mandatory work placement, or engage in a programme of intensive activity.
To ensure fairness to the taxpayer, it is right that there are consequences for those who refuse to engage with the support on offer. It comes back to my initial comments at the beginning of my remarks. As a result of this new approach, no claimant should reach 18 months of unemployment in receipt of their full benefits if they have not taken every reasonable step to comply with jobcentre support. The noble Baroness, Lady Bennett of Manor Castle, asked about the additional jobcentre support—the AJS. She asked whether this was even proven to work. Perhaps I can reassure her that there is good evidence to show that work is generally good for physical and mental health and well-being, whereas worklessness is associated with poorer physical and mental health and well-being. Work can be therapeutic and can reverse the adverse health effects of unemployment. This is why the AJS aims to support those closest to the labour market to return to work as quickly as possible and prevent long-term unemployment. So we do think this is a very worthwhile project. It will send a clear message to claimants who can work about engaging properly with support.
Having covered that area, I will now focus on the important points that were raised about claim closure. I would like to, I hope, give some reassurance, and dispel a few myths which were put about. I listened carefully to the remarks made by the noble Lord, Lord Davies, whom I have much respect for. However, I am afraid that I just did not agree with much of what he said in this respect. It is important to underline that not everyone who fails to meet with their work coach is subject to a sanction. If you have good reason, you will not be sanctioned, nor will your claim be closed. The examples of “acceptable good reasons” include new or worsening illnesses, health condition flare-ups and periods of mental ill-health—which answers a question raised by another noble Lord. They also include working or attending an interview, unexpected childcare, attending the funeral of a close family member or friend, or transport failures.
Even if there is no evidence of good reason, work coaches can also apply discretionary easements, as mentioned earlier, such as domestic emergencies. When an easement is in place, we relax our requirements so that individuals will not be sanctioned, nor will the claim be closed. Still, if you do not have a good reason  for a failure but you take corrective action and re-engage with the support on offer within six months, your sanction will end and your claim will not be closed.
The noble Baroness, Lady Sherlock, asked who these people were, and I hope I can help to answer that. There is a rapidly growing group of disengaged claimants, as the right reverend Prelate acknowledged, on nil award, who have had a failure without good reason and have failed to re-engage for more than six months. They have no housing or child elements attached to their claim. Crucially, this means that claimants who do have housing costs or children can rest assured that they will not be at risk of losing the income that they have come to depend on.
In addition, the people in the impacted group have not declared that they are homeless or, because they have no housing element, they are likely living with family, possibly including their parents, or their friends. We also exclude any claimant with a health condition that impedes their ability to look for or carry out work—which might play into the questions raised by the noble Baroness, Lady Bennett. It is therefore only right that we close the loophole that allows people to continue to maintain a claim without complying with any commitments.
In the remaining time, I will focus particularly on free prescriptions. This was another theme raised by the right reverend Prelate. Not everyone who is subject to a claim closure will lose access to free prescriptions. There is a variety of exemption criteria beyond receiving universal credit that would qualify an individual for free prescriptions. Claimants are entitled to help with health costs, including free prescriptions, only if they are in receipt of a monetary award of universal credit that is above zero and if their earnings in their last assessment period were below the income thresholds. Many will have stopped receiving access to free prescriptions when their claims were fully reduced by the sanction.
As always, if entitlement to other benefits is reliant solely on a universal credit claim to establish eligibility, that eligibility will cease if the claim is closed. By excluding the claimants who have more severe health conditions and vulnerabilities from sanctions, we believe that the claim closure group would likely be claiming prescriptions for only minor health conditions. I think the right reverend Prelate acknowledged this in her remarks.
There were a number of questions, particularly from the noble Lord, Lord Davies of Brixton, pressing me on the lack of support for the most vulnerable. I hope I can be a bit more helpful. A well-established system of hardship payments is available as a safeguard if a claimant demonstrates that they cannot meet their immediate and most essential needs, including accommodation, heating, food and hygiene, as a result of their sanction. In universal credit, claimants are able to apply for a hardship payment from the first assessment period the sanction reduction is applied.
The noble Lord, Lord Davies, asked about work being the best route out of poverty. He knows what my reply will be, which is that the Government are committed to a sustainable long-term approach to tackling poverty and supporting people on lower incomes. He is well aware of the expenditure that the Government are  making in this area and we believe that the best route out of poverty is through work. The Government remain committed to a sustainable, long-term approach in this respect.
The noble Baroness, Lady Bennett, asked about abolishing the prescription charge. I say very briefly that the Government have no plans to abolish the prescription charge in England or to review the medical exemption qualifying list. Our policy remains to help those whose need is greatest through the rules we currently have in place.
I really ought to finish. There are a number of questions that I will most certainly answer—

Baroness Sherlock: I am sure that the Minister will write, but I will ask one simple question before we are timed out: how many people could be affected by this policy?

Viscount Younger of Leckie: I have asked about that figure. I will need to check whether I can give it to the noble Baroness, as it is not in the public domain. It is substantial. I will write to her to give her whatever answer I can. It is a very fair question, which was also raised by the right reverend Prelate the Bishop of London. However, that is as far as I am able to go.

Baroness Bennett of Manor Castle: Could the noble Viscount put that in the Library and share it with everyone in this debate?

Viscount Younger of Leckie: I will most certainly do that.
I will conclude briefly, because time has run out. I have not had a chance to focus on safeguards, which the noble Baroness, Lady Sherlock, raised. I will write to her on that as there is quite a lot to say. I close by saying that our Back to Work plan is about putting fairness at the heart of our welfare system: fairness for claimants who play by the rules and try their best, and fairness for taxpayers who contribute to the welfare system. Above all, it is about helping those who can work to move into jobs, which will grow our economy, change lives and, indeed, change their own lives.

Early Years Education
 - Motion to Take Note

Baroness Andrews: Moved by Baroness Andrews
That this House takes note of the importance of good quality early years education provision and environments, particularly since the COVID-19 pandemic.

Baroness Andrews: My Lords, this debate could not be more timely. I am extremely grateful to noble Lords who have put their name down to speak this afternoon, despite the hour and the weather.
In the spring Budget, the Government made £4.3 billion of new investment to expand entitlement to childcare. For children between nine months and three years, who will be offered 30 hours of funded—not free—childcare per week from April 2024, this was extremely  welcome. I want the Minister to know that we are grateful indeed for, and acknowledge the significance of, that investment. Why was this new funding therefore received by the childcare sector with more alarm than joy? Briefly, it is because it has become clear over the past seven years that the sector is simply too fragile to deliver additional places at the price that the Government are prepared to pay for them, without putting even more providers at risk and adding to the potential erosion of the service. Since the Government are actually purchasing about 80% of all childcare hours the providers, especially in the poorer areas, will be made even more vulnerable because there will be less scope for asking richer parents to pay more.
At the heart of this issue, therefore, is the chronic and cumulative underfunding of the existing provision for three to four year-olds, which led the Institute for Fiscal Studies to estimate yesterday that funding was 10% below that which it was in 2012, and that funding will simply not reach many of the poorest families at all. It is that which is raising the alarm now among providers and parents, and that alarm is shared by the Select Committee on Education, which reported in July that without every effort, the extra places cannot be delivered—and possibly cannot be delivered without risk—and that the existing places may become more vulnerable.
Yesterday, the Government announced that £400 million would be available for the policy. Again, that is welcome news but, in a complicated funding environment, I have to ask the Minister for further clarity. Can she tell me whether this, or a proportion of it, is new money? What and who, and exactly how, will it be funding? Can she just give us those details for greater clarity? How will it improve the situation for the many existing providers who provide just for three to four year-olds? How will it incentivise those who want to expand the service to the younger children?
When there is such huge investment at stake, it is really dispiriting that we cannot be certain that, with the best intention, extra places can be provided, that objectives will be met and that there will not be such perverse outcomes. Those perverse outcomes were baked into the Childcare Act 2016. It gives me no pleasure to say this but I and many others, informed by the childcare networks, warned in this House then that unless places were fully funded, there would be an exodus of providers that could not afford to bear the burden of expansion. It turned out that the funding provided was a quarter of what was estimated to be needed.
I also make the point that the Government’s own objectives short-changed the children involved. While the emphasis was on getting parents back into work, there was no equivalent urgency or assurance on quality or educational outcomes, especially for those with special needs. The child, it seemed, had been left out of the policy—so it still seems, but it is so much worse now after Covid. In the short term, we can already see the impacts: the sustained loss of language, learning and socialisation in very young children, which is of course worse in disadvantaged areas; a wildfire of absenteeism in secondary schools; and a breakdown of some basic trust between parents and schools about  the value of attendance. Then there is the ultimate broken environment: the crumbling concrete, which puts children and teachers at risk.
I have enormous respect for the Minister. This policy is not of her making but I know that she and her colleagues, like us, want it to succeed. She will also know that when I say that childcare provision has been knowingly underfunded, I am referring to the information obtained directly from her department, revealed by a freedom of information request from the Early Years Alliance, which shows that in 2015 DfE officials were already worried about a funding gap and had already estimated that, by 2021, the hourly costs for funded-hours entitlement for three and four year-olds would reach £7.49. In 2021, however, providers were receiving only £4.89 for each place.
The foundations were being undermined from the start, because the original gap between what the Government were prepared to pay for and what it actually costs to care for and educate a young child has widened every year, accelerated by inflation, the cost of living increases and minimum wage increases. In 2024, providers will get £5.62 per place. The sector estimates that the real cost is over £9.
What is clear is that, across all comparisons, the UK is still the third most expensive of all OECD countries for childcare. This bears down most on families who earn less than £45,000; they do not qualify for universal credit but cannot afford the £14,000 now estimated as the annual cost of one child in full-time preschool care. Parents and children are falling through the cracks. But the present crisis is not just about financial shortfall; there was another gross failure in 2015. Staffing accounts for 70% of costs. What was crucially needed was a workforce plan in place dedicated to building the childcare workforce of the future, with provision for training and professional development and a clear focus on learning outcomes. That did not happen.
Instead, funding was grafted on to a service which was already struggling with retention and recruitment. Ofsted has shown that the service has shrunk from 85,000 providers to 60,000 since 2015. According to the Early Education and Childcare Coalition and the University of Leeds, 57% of nursery staff and 38% of childminders are considering leaving the service in the next 12 months. A workforce plan is more urgent now. We cannot start soon enough. I urge the Minister to go back to her department and urge her colleagues to put in place the beginnings of a workforce strategy, because it is in the poorest areas that we have the greatest impacts as it is where children’s preparation for school and attainment in school is lowest.
I am afraid I have a few more statistics. Half of providers exist just on the margins of profitability. The National Day Nursery Association estimates that the average setting has lost £32,000 as a result of those 15-hour places for three to four year-olds, and 96% of those were good or outstanding; these are not poor providers. Ofsted’s latest figures—from August 2022—up to now show a loss of 3,200 additional providers. The fastest exodus from the profession is by childminders, who are becoming an endangered profession. Of all  these statistics, the most alarming I have seen is an estimate that by 2035 there will be only 1,000 childminders left in the UK.
To be graphic, what we are watching is a system which has been unequal from the start become more unequal, more unfair and more inefficient. Women are still being held out of the workplace and we need them to be as fulfilled and as productive as possible, particularly in the poorest areas. The Early Years Alliance is a good example. It is one of the largest community-based providers. It has 132 settings four years ago in the most deprived areas; now it has 42. It is in the childcare deserts that childminders have left at the fastest rates. They are the areas where the pressures on preschool settings are the greatest because there are so many fewer high earners who can help cross-subsidise the system. When 80% of those places are funded for poor families, you do not have the scope to borrow and cross-subsidise. You have two choices; cut the hours of your staff or cut your staff entirely. Perhaps the Minister will say that a low take-up reflects lower birth rates or that women are choosing to work from home more. If she does, I urge her to give us the evidence for that.
We can all agree that we will never deliver for children unless the Government deliver for the early years’ educators, who feel “undervalued” and “under-respected”, in their words. We really need a review of pay and conditions. Nearly half of them survive on benefits or tax credits. The Sun recently put out an article with the 20 least popular jobs in the country. At the bottom of the list, earning about £22,000, were early years educators. What does that say about the value we put on children? It is estimated that it would take five early years educators pooling their resources to afford an average-price house.
I have a few related questions. Why was there no reference at all in the Autumn Statement to the impact of higher minimum wages on those caring for three to four year-olds? Exactly how many new places are expected to be created for younger children with the new money? How many new staff will be needed, and how will they be found and retained? What is the plan?
What is the estimate of the number of younger children under the new scheme who will come from families on universal credit? How will that be evaluated? Has DfE made any estimate of the amount of dead weight—parents who are presently paying but who will move, by different means, on to the funded places? How is that being evaluated? Why have the Government rejected all the evidence from the sector and parents about the change in the ratio from 4.1 to 5.1 staff, which is going ahead despite all the evidence that this will cause retention to deteriorate further? Why, in the spring, did the Government not consult or even inform the sector regarding the planned expansion before it was announced? It read about it in the newspaper.
Why have the Government rejected Select Committee’s arguments on the need for sustainability by rejecting recommendations on the right rate of funding for all ages and the abolition of business rates? This is a unique sector with a unique national public service to offer, and it would make a massive difference if business rates were removed. Is the Minister prepared to meet  with the Early Education and Childcare Coalition and the Early Years Alliance to listen to their shared concerns?
There is no need to rehearse the importance of early learning: we have decades of evidence on how and why these years have the most profound impact on what people make of their lives—speech and language, curiosity, relationships and behaviour. A threadbare, uncertain and stressful environment holds every child back. These are the same children who suffered so badly by being locked out because of Covid, and whose parents could not provide the books, the companionship, the conversation, the outdoor play, the stimulation.
The evidence is piling up. Ofsted has charted the continuing impact on child development, such as language and learning loss, and more children needing specialist help and waiting longer. The Education Policy Institute has said that according to the evidence, the disadvantage gap between poor children and the rest, which has been much reduced over the past decade, has been “reversed”. In June this year, the Public Accounts Committee noted in relation to older children that Covid had wiped out a “decade of progress” in reducing the attainment gap. This is really serious. The Children’s Commissioner told the Covid inquiry that children and the child’s perspective were entirely left out of Covid planning. It is worth reading all 130 pages of her evidence.
One of the most conspicuous failures has been not following the powerful and expert advice of Sir Kevan Collins. What was wanted for secondary and primary school children was a properly funded, coherent, active-learning programme that was not simply tutoring, but which brought enrichment, motivation and an appetite to learn. I know that because I spent much of my life in that sector.
No one in the Chamber disputes the link between children in poverty and school failure, nor how the number has grown. No one disputes that putting the childcare sector on a stable footing and making that investment work properly is as much about expanding the minds of children as it is about expanding the economy, and the care economy in particular, which underpins it all. It is about ensuring that the future is in safe, intelligent and courageous hands.
This why the current situation is so profoundly frustrating and dispiriting, and I have some sympathy with Ministers in this respect. We seem to have ended up with a Treasury model focused on childcare, not children. Children are invisible and their value is commodified into the cost of places, rather than optimising the benefits to them. Although the additional funding this spring and the announcement yesterday are of course welcome, they do not put right the profound structural problems that will make it so difficult to deliver this policy, which we all want to see—indeed, they could make it worse.
If the evidence in the next few months shows that there is an issue with delivery, I urge the Government to listen to what the sector tells them and not to short-change providers, parents and children. We need to assert that every child matters, and we need to see this at the centre of every government policy, in bold  caps. Otherwise, after years of failing to provide, this will be the generation that was promised more but given less.

Baroness Kidron: My Lords, last week I introduced a debate on the impact of edtech on the learning, social development and privacy of children, and more than one noble Lord stood up and said that they were an expert not on tech but on education. So, this afternoon, I hope noble Lords will bear with me because I am standing up and saying that I am not an expert in education but rather in tech, and it is from that perspective that I will make my contribution.
I declare my interests as in the register, specifically as adviser to the AI Institute in Oxford and fellow of the computer department there, and chair of the Digital Futures for Children Centre at the LSE, and of the 5Rights Foundation.
Technology is neither the enemy nor the salvation of the education sector, whether for school age or early-years children. It has magical qualities of interactivity, transporting children to places and spaces they would otherwise not experience. It has the benefit of consistency and predictability, so a good programme or experience can be reproduced an infinite number of times. Technology is multifaceted: it contributes to complex management systems, delivery of services, learning products, devices, safety tech—and, of course, that includes technology that we consider part of the fabric of a child’s life, from TV to radio to talking toys. I want to make it clear at the outset that it is not technology itself but rather the gaps between how it is being sold, used and governed that I seek to highlight.
In June 2022, Nesta, as part of its mission to close the gaps in school readiness, undertook to see whether it could harness the trend of increasing screentime to narrow the gap in language, maths and literacy experienced by children from low-income households. The Nesta report is relentlessly optimistic in assuming a positive role for digital tech, yet the first three of its four key findings were that it is imperative to improve the quality of toddler tech, so it delivers greater benefit for children’s social, emotional and cognitive development; to help parents navigate a crowded market, so it is easier to identify apps worth their children’s time; and to make high-quality content freely available to low-income families. This third recommendation came on the back of the finding that 88% of toddler apps had in-app advertising, 70% had in-app purchases, meaning that you had to pay to progress in a puzzle or a task, and 58% of all of them had low-quality or no educational value at all. The fourth and final recommendation was a call for further research on how technology could boost children’s outcomes.
The Nesta report is worth a read because, even in this refreshingly pro-tech report, the lack of quality in learning and developmental outcomes for children was stark, as was the shameless creation of an advertising market targeted at the under-fives.
I was disturbed to discover that several colleagues recently suggested that there was an outpouring of research showing that early-years development was increasingly inhibited or stalled because of screen use. I asked Children and Screens, at the Institute of Digital  Media and Child Development in the United States, to share its evidence of tech impact on early years. With something of a spoiler alert, I shall read the conclusion:
“High-quality, age-appropriate educational content can have positive impacts on learning and socioemotional development—but not over and above the effects of traditional learning or interpersonal interactions. There is little research that technology is particularly beneficial for educational outcomes, and screen time (particularly TV and video games) relates to poorer academic performance. Technology can increase access to education (eg remote learning), but rarely if ever improves upon traditional learning in its current uses. In the meantime, excessive screen time and online interactions, without proper safety precautions and literacy, can expose children to harm”.
In the detail of its findings, the institute provided research from around the world showing that more screen use is related to lower scores on language and literacy development; that higher passive screen time— “passive” is the key word in that sentence—relates to worse working memory; and that passive screentime in the first five years of life correlates with problems with attention and concentration, learning rules, cognitive flexibility and hyperactivity. There is also a whole set of other problems if what they are watching is age-inappropriate.
There is a worry that screen time is currently, and increasingly, displacing peer play in one to three year-olds, resulting in poorer social development. There is a problem with the quality of what children are seeing or doing, whether they are doing it alone or with a carer, and the opportunity cost—that is, what they are not doing while they are looking at the screen. There is also a problem of widespread privacy and safety concerns in an entirely unregulated market. Then there is the problem of the Government’s response, because while the Government have taken a robust view of the need to regulate tech, particularly in relation to children, they have consistently exempted educational settings, creating a bizarre situation where a child’s privacy and safety protections are worse in education and care settings than they are outside. Leaving tech outside any formal oversight has resulted in the free flow of products and services that claim to be educational but have no right or reason to be considered educational and are gathering children’s personal data at an alarming rate.
While the age appropriate design code brought forward in the Data Protection Act 2018, started in this very Chamber, brought in wide-ranging design changes to tech platforms to protect children’s privacy, an exemption is made for schools and education settings. In many cases, edtech providers do not have to provide the high bar of privacy by design afforded by the AADC, the impact of which I set out last week in debate and can be found in Hansard. In short, there is an eyewatering flood of children’s personal and intimate data straight into the commercial sector.
Similarly, however much I welcome the Online Safety Act, it states:
“A user-to-user service or a search service is exempt if … the provider of the service is … the person with legal responsibility for education or childcare … a person who is employed or engaged to provide education or childcare”
or if
“the service is provided for the purposes of that education or childcare”.
The true impact of this exemption will not be fully understood until we see the detail of Ofcom’s children’s code, but I believe that it will result in some rather contradictory outcomes in which tech providers have fewer duties to children in education and childcare settings than when they access the same or similar services from a bus.
Turning to the need for standards and certification of the tech itself, I want to briefly mention, as I did last week, the work of Dr Laura Outhwaite, a researcher from UCL, who while looking at maths apps for under-fives found that of the top 25 only one had been peer reviewed, half did not meet good practice of learning support and six had no maths content at all.
There is a consensus across many studies and academics that edtech that is worth a child’s time needs four things. It needs to promote active learning, which means activating mental activity on the child’s part and not just clicking or swiping. It needs to consist of learning material, which means engaging with, rather than distracting from, the learning goal—that is, it needs to not include advertising, mini-games or other things that distract and collect data. It needs to be meaningful and relatable, which means providing scaffolding from what children already know or can relate to to support new learning. It needs to include social interaction. That is key, since passive watching has significantly poorer outcomes, so it should encourage interpersonal interaction and use parasocial relationships rather than encouraging exclusively solo play. In addition to those four requirements, children at schools and in early years provision should be afforded privacy and safety equal to or greater than that afforded in other settings.
On the idea that the provision of, and compliance with, safeguarding standards that are routinely delivered by school and carers is equal to the ICO, Ofcom or an edtech standards and certification body—which currently does not exist but is sorely needed—I ask noble Lords to imagine why we expect a nursery teacher to check the privacy or security of an app. Why is it okay for a company to provide a sales pitch to a teacher or a school leader that fails to mention that there is no, or poor, educational benefit, as is found in 58% of edtech?
That rather disheartening list should be seen in the context that high-quality digital media that encourages engagement and conversation can inspire and educate even the youngest child, which means that the quality and format of what children are given matter, in many cases just as much as the amount of time they are doing it and whether they are using tech in a shared context with truly interested and focused adult engagement. Although it remains the view of paediatric associations both here and in the US that under-twos should have no screen time other than for video calling, there are real opportunities that we are missing because of the poor oversight and wrongheaded view that schools and early years safeguarding adequately covers tech from a regulatory point of view. At the same time, we provide no standards for the tech itself.
I want to associate myself with the comments of the noble Baroness, Lady Andrews, and add to her concerns that where money is an issue, tech is often considered to be the answer. I urge all noble Lords to take seriously the role of tech in this situation.
I have been raising these issues for some time with Ministers, regulators and in debates about technology, and I hope that in joining with those of you who are experts in education, we can focus on something which I believe to be, at best, a terrible oversight and, at worst, a failure to respond to a known harm, or a series of known harms, and that together we can address these issues across disciplines.
Before I sit down, I have a couple to questions for the Minister, some of which will be familiar to her. Does she agree that it would benefit children, parents, teachers and carers if there were a system of certification and quality control across the edtech sector, and that the privacy of children in school, where data shared is both sensitive and compulsory to provide, is an urgent matter and should be covered by the upcoming data protection Bill? That would be a useful conversation between the education department and DSIT. Will the Minister agree to ask officials to consider formally how the decision to exempt from the Online Safety Act schools and early learning might impact children in education and childcare settings? I look forward to her response.

Baroness Goudie: My Lords, I thank my noble friend Lady Andrews for bringing this crucial topic to the House. It is vital that this Government think seriously about early education and implement strategies to mitigate the awful reductions in education attainment across the whole spectrum of school age groups, made significantly worse since the Covid-19 pandemic.
We all know that a child, even before it is born, can feel a whole lot of aspects that are going on through its mother’s womb, including violence and calmness. So when the child is born, it is absolutely vital that it starts to have early education, including in the home. That is why Sure Start projects should be reinstated, so that mothers, fathers or carers can take children to groups to start them being social at a very early age and so that they learn to share, talk and behave and learn all the aspects that my noble friend spoke about earlier through apps and so on. I am very pleased about her lecture; I will send it on to others, as many parents and care workers need to know about that. I thank her so much.
Why are early years important? When discussing childhood education, preschool often gets relegated to the sidelines, as if it were somehow of secondary importance compared with primary and secondary schooling. Pre-education gives the ground rules and start to every child. We like to say that every child is born equal, but if they are not having preschool and that sort of help in the home and outside, they will be losing already. If we look at how children develop—and, importantly, when they develop—we may become inclined to pay a little more attention to this overlooked phase of our children’s development journey.
The simple fact is that early years education tremendously impacts on lifelong achievements. The majority of all development occurs during the very first years in this world, and 85% of our language is cemented before the age of five. I can tell that with young children around me. That is even more so these days, when it is even quicker; for some reason, they grasp things much faster. Between the ages of 18 months and five years, a child goes from knowing approximately 50 words to using around 2,000 and understanding some 5,000 more. This kind of rapid development happens at no other time during our lives, and the same pattern of booming cognitive ability happens in other areas, too, including physical, psycho-emotional and cognitive ability. All these skills are the foundations that later learning and development are built on. That is why we have to invest more. If a child has encountered disadvantages during this time, this has already had an effect.
According to the Times Education Commission,
“40 per cent of the attainment gap that can be seen at the age of 16 is already in place before those children even start school”.
So a bad start at an early age can never be made up; we know that education cannot be made up for those children who start school as late as five. The commission states:
“A child’s development score as young at 22 months is”
the
“predictor of where they will be educationally at the age of 26”.
That is very frightening, but we know that it is the truth.
Often, the entire process has occurred before a child has encountered a teacher. The importance of properly funded, well-trained and well-staffed preschool education has gone entirely amiss under this Government. The decision to increase staff-to-child ratios in early years settings sends a clear signal, because children need people to look after them. You cannot increase how many children the teacher or carer will look after; we should decrease the number of children they have to look after, so that the children can get much more attention. This is sending a clear signal that, instead of giving the sector the much-needed investment it needs, they would rather lower the standards of care available—at the moment of a child’s life that is arguably the most important.
Another important issue with going to childcare or nursery schools is food. We know that a child and its brain cannot function without food—we have to understand this. It is vital that we provide more breakfast clubs, so that children get food when they go to nursery. Those who cannot afford that should be given free food. Also, we should have free school meals, including during the holidays, which is a very difficult time. This will affect the generations to come and we will not be a country that is fast flowing if we do not invest in our young people from the very beginning.
These decisions on the quality of preschool education affect not only the child’s attainment but the economy and our society at large. The Times estimated that, for every £1 spent on early education, £13 would be saved later. That is not a lot of money when added up over a long time. The money will be saved later in a child’s life in education, catch-up interventions and, more importantly, mental health and health. Research from  the Effective Pre-School, Primary and Secondary Education project showed that children who attend preschool have better education and social outcomes at the end of primary and secondary education, and have higher GCSE scores and the potential for higher earnings.
I come to Covid and post-pandemic changes to early years education. For children, we can even say that the pandemic is not fully over. They continue to be impacted by the effects of lockdown measures, and it is still difficult to ascertain just how harmful the pandemic period has been on their development. That applies in particular to those who were locked in high-rise flats with nowhere to turn, who had balconies but could not go out on them because it was unsafe and who received no education, with no way of ascertaining anything with regard to preschool.
During the first national lockdown, early years settings experienced partial closures, permitting only children of key workers and those considered vulnerable. Who decides whether a child is vulnerable? A child can be vulnerable in a rich family or a poor family—all sorts of factors determine that decision. Despite subsequent lockdowns allowing preschools to remain open in many circumstances, statistics released by the Department for Education in December 2021 highlighted that attendance levels had not reverted to their pre-pandemic status. We see that today with children who are not attending school, and the numbers of those who are not attending preschool are even worse. Parents are keeping children at home because of costs, but that is damaging that child beyond damage. Consequent numbers of children have missed out on valuable guidance from early years practitioners.
Families continue to grapple with the challenge of balancing childcare alongside remote work, health concerns and the cost of living crisis, which has meant that many cannot afford full-time preschool. That is why we have to have nursery schools attached to schools; regardless of the cost, this is vital to the country. Additionally, a report from the Children’s Commissioner has revealed that a substantial number of children endured adverse circumstances during lockdown, including experiences of poverty, exposure to domestic violence, parental mental health challenges, instances of parental abuse and even more violence.
Early years education needs to be taken as seriously and given as much time and attention as primary and secondary education. The early years education system needs reform, and quickly, if barriers to entry are going to be broken, especially if they exist alongside the wealth divide. We must place more nurseries in primary schools and integrate early years into the more formal education sector. This would not only help bring down costs for parents of young children and babies but would also help to standardise and improve the levels of care and education delivered at a young age.
Early years educators should be on the same pay scale as primary educators, and more teaching graduates need to be brought into the profession and encouraged. Our early years facilities are closing down at alarming rates, and educators are leaving the field en masse.  Much of this issue stems from early years underfunding and undercaring, and the idea that this area does not matter, and children can go to school at five but not before—that is it. The Government, and any Government after them, must put investment in the early years education sector central to any long-term strategy for education.
I will say a word about families and children of refugees in this country. Many families have come to this country not as refugees but sometimes because they have been displaced by war or climate change. Those children should be in school and should have the advantage of preschool as well; over the years they have and they have not. These are the future generations and it is about our soft power; they may decide to stay here or to go elsewhere, but we need to take care of those families properly because they will be our partners as the world goes further.
I come back to say that, when you are thinking about moving refugee families, think about the children’s education, including their preschool education, and their health. That is vital; otherwise, it will cost those families, the country and the world much more. We should take that more into consideration when we are moving children of refugees abruptly.

Baroness Bennett of Manor Castle: My Lords, it is a pleasure to follow the noble Baroness, Lady Goudie, and to share her passionate concern about the level of inequality that affects children’s start in life and therefore affects people throughout their lives.
I have been enjoying taking part in this debate and am particularly glad that the noble Baroness, Lady Kidron, brought her expertise to this afternoon’s session. I was particularly interested in her focus on advertising built into apps, built into systems where parents feel as if they are doing the right thing by exposing their children to them. It is the Green Party’s policy to ban all advertising targeted at children of primary school age or under, because there is psychological evidence that shows that children are unable to distinguish between editorial content and advertising content—where, indeed, there is a difference between those two. I understand that it may not be in her brief, but I ask the Minister later, if possible, to say what actions the Government plan to crack down on advertising aimed at a vulnerable population with no way of understanding that what has been targeted at it is advertising.
I particularly thank the noble Baroness, Lady Andrews, for giving us the opportunity for this debate and for introducing it so powerfully. I have crossed out quite a number of things in my speech in an attempt not to repeat but rather to add to what has been said in this debate. I note that for the second debate in a row, there are no Tory Back-Bench speakers. I have to draw the contrast between this debate and yesterday’s debate on the Autumn Statement, where we saw a large number of speakers with a very different gender balance. I urge those who participated in yesterday’s debate, if they read the Hansard of this debate, to think about the fact that if they will not think or care about early childhood education for other reasons, they should at least acknowledge this is the foundation of our economy. In yesterday’s debate, we were—as we are practically  every day in the House—lamenting the terrible level of productivity in the UK. Where is the foundation of that? With our inadequate early years provision. If you will not care about it for other reasons, please think about caring about it for that great god of the economy.
The noble Baroness, Lady Andrews, in setting up this debate, focused on the impact of Covid, and we have already heard very powerful testimony about that, but it has exacerbated problems right through our education system from early years onwards. Of course, when children leave the early years system, they go immediately to baseline testing. Then, in primary schools they have SATs and all the pressure, worry and concern that they raise. Our whole education system is focused on teaching to the test, treating children like an empty vessel into which a whole lot of information is poured. They are shaped into a work-ready form. I go back to 2013 and the then Childcare Minister, Liz Truss—you might remember her. Liz Truss, having, in her position as Minister, toured a number of early years settings, said:
“I have seen too many chaotic settings, where children are running around. There’s no sense of purpose”.
I ask the Minister if that still reflects the philosophy and approach of the Government.
As an alternative approach that I think the Government should be taking, I will point her towards the work of Paul Ramchandani, the world’s first Professor of Play in Education, Development and Learning, who is based at the University of Cambridge. I encourage the department to look at the professor’s work, which very much focuses in the early years setting on the fact that that play is fundamental for children to learn and develop. For younger children, that is where they learn to communicate, to share, to interact with other children and to manage their emotions when things do not work out. There is an excellent article in the Times Education Supplement covering this much more broadly than I have time to today. Does the Minister agree that early years education has to be focused on the development of the whole child, rather than making them school-ready in the narrow Liz Truss sense?
In addressing this debate, I have three sections: philosophy, staff and some inequality points, building on the comments of the noble Baroness, Lady Goudie.
One of the things to think about in the Green Party philosophy is that early years education should go on for longer. In many countries, academic learning is not introduced until the age of seven. These early years should be regarded as a unique educational stage in their own right, not just as preparation for school. Here is one of the practical realities that we see: I am sure that many of the noble Lords taking part in this debate are regularly contacted by parents who are concerned about their child being the youngest in the year and struggling developmentally to keep up with children who are almost a year older than them. We need to recognise the variance in children’s development and give them the chance to develop in that early years setting, which should—indeed, can—be much more flexible and adaptable than a school setting could ever possibly be.
We think that we should see a movement towards the early years going on for longer. One thing that is really important, but which much of our early years provision does not currently enable, is regular access to outdoor green spaces and nature. We are very much aware of the fact that this has both educational and health benefits. We now understand that the human microbiome is crucial to our well-being. Being in natural environments, for example playing in the mud, has all kinds of health benefits to which, sadly, many of our young children simply do not have access either in their early years setting or in their home environment. The science shows us that the benefits are huge. I do not know whether the Minister can offer me any hope that the Government acknowledge the importance of that exposure to the natural world—that is, physically being in the natural world. Can she say whether the Government have any plans to increase that opportunity?
I come to staffing, which the noble Baroness, Lady Andrews, has already covered quite a bit; I will lean heavily here on the Early Education and Childcare Coalition’s report, prepared with the Women’s Budget Group. The Government are talking; I welcome them saying, “We need to expand early years provision and improve the quality”. However, the coalition’s figures show that 57% of nursery staff are planning to leave their jobs in the next year, while two-thirds of nurseries are already reporting an average waiting time of six months for a place. We have a long-term situation where car mechanics are generally paid far more than childcare workers. This is an old feminist commentary on the gendered nature of those two roles, of course, but we have to acknowledge that this issue is crucial for all our futures. We need to value our workers.
Some of the practical recommendations from the coalition are really worth focusing on; they are not necessarily enormously expensive. They include having a career development hub at the Department for Education, because one thing that this study and others have very much focused on is the fact that there is not really any way for people to develop their skills practically. Nurseries are often understaffed and struggle to keep up with the legislative requirements on staffing levels. Their ability to have time for staff to go away for training and further development just is not there. What is also crucial—I will come back to this—is the need for more special educational needs training so that we can meet the increasing demands for special educational needs provision in early years education.
Further to that point about allowing staff to go away for training, the report recommends a system of having bank staff at the local authority level to enable staff to take time out for training. This would mean that staff could do so without any negative implications for their employer. There is also the experts and mentoring scheme for childminders. Do the Government plan for that to become a permanent programme?
I will finish with a point that I have raised before with the Minister and cannot avoid raising in this context, as we are focusing so broadly on the early years sector—the rising number of hedge funds and those in the financial sector investing in it. These people are not running nurseries because they are passionate about children’s development or because  they really want to make a difference. By definition, they are there to make a profit. There are now 81,500 childcare places in England owned by investment funds and similar organisations. That is almost double the total in 2018.
A report from UCL academics last year said that these are very risky financial models, heavily indebted and at real risk of collapse—as we have seen in the care home sector. I put this on the record because I suspect that many parents do not realise the role of the financial sector in their provision. We all know how desperately parents have to hunt around for a place and then grab what they can, but I wonder whether they know that Busy Bees Nurseries is owned by the Ontario Teachers’ Pension Plan. Kids Planet is owned by the private equity firm Fremman Capital, which has recently been on a large buying spree of expansion. The Dutch private equity firm Waterland recently acquired Partou. The London-based Oakley Capital owns what it renamed the Bright Stars Nursery Group, which is one of the fastest growing.
We are talking about something fundamental. We are talking about the future—and we are not doing very well.

Lord Brooke of Alverthorpe: My Lords, it is a great pleasure to follow the noble Baroness. What a fascinating and wide-ranging debate this has proved to be. I am grateful to my noble friend Lady Andrews for securing the debate and for the excellent way in which she introduced it. I note that I am the first male to speak. I spoke to her about whether I should put my name down as I thought I would be rather wide of the mark, but as I listened to the contributions, particularly from my noble friend Lady Goudie on free school meals, I recognised that, rather like the noble Baroness, Lady Kidron, while I am not an expert on education I have spent a bit of time working on health.
When we look at the totality of what influences babies and children in their early years and children early on in school, all these important factors come together—media, the environment, what we eat and do not eat, what we are taught. My contribution will, I am sure, make the Minister groan, as we have been on the subject as recently as two weeks ago: what we feed our children and what we do not feed our children but should. I declare an interest as a founding member of the All-Party Group on Nutrition: Science and Health and as a vice-chair of the All-Party Group on Obesity. In recent years I have increasingly spent more time on children and obesity than on adult obesity.
Labour has an extraordinarily good record. We should keep saying this over the coming months. Back at the turn of the century, the Labour Government then in power started to get concerned about the growth in obesity among schoolchildren and babies. There was a programme on the radio today about babies’ food. One of the big issues is the amount of sugar that we are feeding to babies, unbeknown to many parents as they feed their children. I declare my interest as a patron of a small charity, Sugarwise, which was founded by a woman who happened to look at the ingredients in what she was feeding her  baby. She was astounded by the high element of sugar that her child was being fed, which she believed had an influence. It continues and there is a very big case for further work to be done on babies’ food, but today I am looking at schoolchildren.
The Labour Government were concerned about children aged three to four, and upwards, that were starting to put on weight. In 2006, after doing some research, they introduced the national child measurement programme to check the height and weight of most schoolchildren from age four to five and 10 and 11. It has now also gone into school breakfasts. The aim was to track the changes that were taking place with children’s height and weight, to assess whether they were overweight and if they were then to try to take measures in conjunction with local schools and parents to try to reverse the growth in obesity. In 2007, they turned their attention to school meals because they recognised that, if they were to influence the course of events on health, this was the area where they had the greatest scope. They examined the quality of school meals and then in 2008 devised a programme to produce a set of regulations on the quality of school meals being presented to our children. Unfortunately, we went out of power in 2010, but that was a very ambitious and comprehensive programme. What a great pity that we were not able to stay in power and enforce those regulations properly, as we would not be facing the problems we now have with our young children.
In 2013, the coalition Government decided to do a review of those regulations governing the quality of school meals, and they changed them. There was concern about insufficient energy in the definitions, so they eased the rules—believe it or not—so that it was possible to increase the amount of sugar in the meals. The Front Bench of the Lib Dems have some responsibility for this, as they were then part of the coalition. I do not know whether they agreed with what was happening in the coalition Government’s internal debates, but they were certainly part of it. Public Health England started getting worried in 2016 about the continued growth in obesity, and it set up a programme aiming to reduce it by 20% in children by 2020. There was then an intention by the Conservative Government to undertake a review of those regulations in 2018-19, but then—in fairness to them—Covid hit us, and they have not had the opportunity to do so.
We have reached a stage where children are continuing to put on weight. Not only that, but we are now starting to identify children aged 10 to 11 with type 2 diabetes. These are people who will have their lives shortened. If this cannot be reversed, they will have attendant problems with ill health in their 40s and 50s, and possibly even end up with amputations taking place. The Government have responsibility in these areas. People like me have been pressing them to undertake this review of the regulations and reduce the amount of sugar that is now permitted to be served to children, early in school as well as at breakfasts, back to at least the level applied by the regulations introduced by the good Labour Government in 2007-08.
My colleagues here, whom I hope will be going into government, should take note of this. They should congratulate the former Labour Government for what they did on this and we should pick that up and run  with it. If the present Government are not prepared to undertake a review of these regulations governing food, the Labour Government in their manifesto should at least be willing to commit to look at the quality of school meals, seek to improve it and reduce the amount of sugar in them.
I pressed the Minister two weeks ago to do that, on the basis of the good messages I heard from her side, her Front Bench and her health spokesperson, and in writing. I thought that there would be a review this autumn, yet I regret that, when the noble Baroness responded two weeks ago, she gave no indication at all that that would happen. I hope the Minister will reflect on that in the light of this House’s decision to set up a special committee to look at ultra-processed food, sugar, fat and salt. That group will be doing that work over the coming year and I hope that I might be a member, as I would press, as your Lordships might expect, that it looks especially at what happens to children. As we have said in so many other areas, what happens in their early years governs their development for the rest of their lives. Without good health, we do not get good education and all that goes with it.
I hope the Minister reflects on whether to do this review, because it is urgently needed. This is not a party-political issue: children are entitled to better food than they are getting at the moment. The Minister may say that it is healthy and nutritious. I think it probably is nutritious, but whether it is healthy is highly questionable, given the amount of sugar that is now going in. I have even been getting complaints from people who produce school meals that they are unhappy about what they have to produce and serve because, with the cost pressures now on them, they feel that they are not able to make the best possible food for children. I hope the Minister reflects on that and maybe redeems the Government by putting in place the review earlier than she had indicated last time we spoke about this.

Lord Storey: My Lords, I reflect on how it was the coalition Government, pushed strongly by their Liberal Democrat element, who brought in free school meals for all key stage 2 pupils.
I remember that my first education essay was on the importance of play—I think I still have a copy of it somewhere—and my second was on good toilet training. That is something on which we can all reflect.
I thank the noble Baroness, Lady Andrews, for initiating this debate and for her important and well-measured speech. Anybody who watched BBC’s main news last night will have seen vividly the effects of the Covid lockdown on three very young children. Their speech, after intensive speech therapy, is only now beginning to develop.
I hope we all know about the importance of early years provision. However, it is too often framed by the needs of working parents, with political parties trying to outbid each other on the number of hours offered, rather than looking at the quality and importance to the development of the child. Early years provision provides the hugely important benefit of social interaction with other children of a similar age—making friends and learning to establish connections, learning to share,  taking turns, listening to others, playing together with other children as well as independently, learning from peers, copying and helping each other. I was quite right about the importance of play. Developing communication skills which will increase their vocabulary and language through a wide range of different situations, learning how to communicate their feelings and opinions, and interacting with peers and adults other than just their parents are vital parts of their development.
Playing with other children also provides an ideal opportunity for them to gain a greater understanding of other people’s feelings—empathy—and increase their own independence and confidence. That added independence can nurture a child’s self-confidence; help to develop their own personality, disposition, thoughts and ideas; and encourage a child to discover more and more about themselves. Learning basic tasks by themselves, taking part in activities and spending time with others develops their confidence and builds a foundation that prepares them not only for school but the outside world.
Early years education is a springboard to learn new skills academically, socially and emotionally. The child will learn new life skills every day, from putting on a raincoat to mathematical concepts, which are valuable to build future foundations. Early years provides routine and structure to a child’s day, including mealtimes, naps, and indoor and outdoor activities. The routine of early years provision helps the child feel more confident, secure and in control of their feelings. Knowing what to expect and when enables a child to play more of an active role in tasks.
Every parent hopes that their child will develop to their full potential, and this is enshrined in Article 6 of the United Nations Convention on the Rights of the Child. However, across England, a significant number of children are not developing the competencies and abilities that they need to start off their lives. At the start of 2022, 154,689 children were missing out on their entitlement. Half of disadvantaged pupils were found to not be at their expected level of development. Good-quality provision is vital for children’s development, equipping them with the foundational physical, cognitive, social and emotional skills needed to be successful in adolescence and adulthood.
I turn to mental health services in early years. I remind the House that, in January, it will be five years since the Government published the NHS Long Term Plan, which promised that mental health services would be comprehensive in covering children aged nought to 19. However, five years on, it is clear that mental health support is coming too late, and the services that support vulnerable babies and toddlers are few and far between. There is, in effect, a baby blind spot. A baby’s early experiences shape their brain development, so getting help early is the key to preventing mental health disorders in children.
In January 2019, the NHS Long Term Plan promised that at least 66,000 women with moderate to severe perinatal mental health difficulties would have access to specialist community care from pre-conception to 24 months after birth. Does the Minister not agree that it is time to set an equivalent target for the next five years, which will drive and increase services that  help vulnerable babies and toddlers? The Government have recognised the need, and they estimate in their Start for Life initiative that 10% of babies are at risk. The Parent-Infant Foundation was among those organisations calling on the Government to set a target for the NHS to support 60,000 vulnerable babies over the next five years who are at risk of developing mental health conditions in childhood.
It always surprises me that, in education, the older you get the more money is spent on you: a sixth-former gets more money than a 12 year-old or 13 year-old, who gets more money than a seven year-old or eight year-old, and a preschool or nursery child gets the least amount of money. That is unbelievable. This is the time of their development, and shapes what they will be like as adults. Yet we as a society—in all political parties; this is not an attack on the Government—have an educational view that the younger you are, the fewer resources and less money you need.
Early years is the most important stage in a child’s life, yet do we invest in quality provision? Do we ensure that staff are well trained and well rewarded, so we attract the best possible people? Do we ensure that there is regular updating of their skills and knowledge? Why do we not have a qualified nursery teacher as head of every early years provision and setting? Here is a radical thought: given that the very life opportunities and rounded development of the child start in early years, should we not consider making early years a statutory/compulsory part of education?

Baroness Twycross: My Lords, I thank my noble friend Lady Andrews for securing this debate. It has been very interesting and varied, with considerable consensus on the need to provide children the best start in life. I declare an interest as London’s deputy mayor for fire and resilience, as I will refer to the problems in securing childcare faced by shift workers, including firefighters, later on in the debate.
However, before I speak on the subject being debated today, I would like to pay tribute to Alistair Darling. There can be few politicians who have contributed so much to this country, both in his leadership in his roles in government and in his leadership in keeping the union intact. I did not have the close friendship with him of so many noble Lords, but unlike many Members I had the privilege of voting for him, in 1997 when I lived in his constituency. I know the thoughts of all noble Lords will be with his family at today’s deeply shocking and sad news.
My noble friend Lady Andrews gave a stark picture of the issues within the early years sector, with areas of deprivation seeing higher loss of provision, to providers simply not being able to take on more government-funded free hours. As highlighted by my noble friend Lady Goudie, there is a wealth of evidence to suggest that the pandemic has impacted the social, physical and communicational development of children. There has to be a focus on how to address this, otherwise a bad situation will continue to get worse and potentially blight the lives of children in this country, both now and throughout their lives.
I welcome the fact that so many speakers today have focused on the child. As my noble friend Lady Andrews has said, the child needs to be at the front and centre in how we plan for and deliver early years education provision and environments. The noble Baroness, Lady Kidron, spoke about what is required to make edtech work for this age group. My noble friend Lady Goudie highlighted the critical skills of language that children need to develop in their early years. Speech and Language UK has identified that, since the Covid-19 lockdowns, a greater number of children face challenges talking. In September, it published a report which found that a growing number of children faced challenges talking and understanding words, from an estimated 1.5 million in 2021 to 1.9 million in 2023.
Labour will ensure that children get support in developing early communication skills, to ensure that every child develops a strong foundation in speech and language development that sets them up to achieve. Labour intends to equip every school with funding to deliver evidence-based early language interventions. For example, the Nuffield Early Language Intervention, which provides small-group language teaching sessions, has been shown to significantly improve the language skills of reception pupils, aged four and five.
I welcome the description of the noble Baroness, Lady Bennett, of the need and value of outdoor play, echoed by the noble Lord, Lord Storey. This and socialisation are clearly vital. The UNICEF UK briefing to Members ahead of today’s debate estimates that around 155,000 children in the UK are missing out on their entitlement to free early childhood education and care. They provided an example of a mother whose son has symptoms of autism, and on that basis had been suspended from his nursery. She was struggling to find a nursery that would accept a child with symptoms of autism but who had not had a diagnosis. For those with a diagnosis, UNICEF UK also described the situation of little support and no clear pathway for it. These are among the children with the greatest need for good early years education: those who can least afford to miss out. However, they and so many others are currently missing out.
As my noble friend Lady Goudie pointed out, it has a hugely harmful impact on all children’s attainment when they miss out on this. Can the Minister tell the House how the Government plan to address this issue, particularly in relation to children with SEN or issues that they await diagnosis on?
My noble friend Lady Andrews referred to the use of the term “fragile” by the sector to describe the precarious present and future state that many providers find themselves in. She quoted some truly shocking statistics about the state of play. The current funding model is forcing many businesses out of the market and many more out of providing free hours. The Tories’ broken hours system has relied for too long, and unofficially, on cross-subsidy, with paid hours and additional costs to parents making up the difference. This means that the Government’s welcome offer of further free hours earlier in the year simply cannot be met. Unless further action is taken, this will be yet another empty promise.
I will not repeat all the statistics used in the debate, but it is not rocket science: childcare businesses are going bust in alarming numbers because their expenses—their costs of doing business—are rising and their income is simply not matching it. Many providers that are still in business are struggling and many simply cannot afford to subsidise the Government’s free hours scheme any longer. A survey of 800 providers by the Early Years Alliance found that only one in five providers that currently offer places to two year-olds plans to deliver additional places under the expanded entitlement. Another third said that they were unsure whether they would deliver places under the new scheme.
As my noble friend Lady Andrews said in her opening remarks, Ofsted figures show that the service has shrunk from 85,000 providers to just 60,000 since 2015. There are now two children for every Ofsted-registered childcare place in England. The knock-on effect is that parents—often mothers—are coming out of the workforce to take care of their child or children. Does the Minister agree that this situation shows that the Government are failing families?
On yesterday’s announcements, the Government have clearly recognised the dire financial state of the sector. However, it is clear from the response of sector representatives that the funding falls far short of what is needed. Can the Minister tell the House what assessment of the sector’s viability and ability to deliver on the commitment of free hours the Government have made, including of the funding required? Given that the announced funding is to go to local authorities, could she tell us how much of it will go to nurseries and childminders, who the chief executive of the Early Years Alliance said yesterday were “still in the dark” as to how much they will receive? Has this now been clarified?
Another major block for delivery in the sector is recruitment and retention. This was highlighted by my noble friend Lady Andrews and others, including the critical need, which is also an ask of the Local Government Association, for a workforce plan. My noble friend mentioned that 57% of nursery staff and 38% of childminders are considering leaving the sector in the next 12 months. This is simply not sustainable.
Can the Minister tell us whether the Government will work with the sector and local government to develop an effective workforce plan focused both on drawing people into the sector and on their ongoing training and development needs, so that the quality of the provision gives children the benefits they need and deserve? If she can commit to this, would she ensure that it also covers childminders and addresses an increasing reliance on childminder agencies—a trend about which the LGA has raised concerns? Early years care will form part of Labour’s workforce strategy, which offers more opportunities through high-quality training and recognition for the skilled work of early years practitioners.
This House recently spent a lot of time discussing levelling up. Childcare and early years education have to be a major part of levelling up children’s chances in life and breaking down barriers to their success. Some small measures related to childcare were added towards the end of the levelling-up Bill’s passage through Parliament. Labour tabled an amendment to allow  councils to run childcare provision themselves when they judge that it is right to do so, not simply as a last resort. I am grateful to the Minister for the Government’s concession to allow this. Will the Government now ensure that local government is encouraged, and given adequate support, to do this to anticipate the current and future needs of their local populations, rather than to try to address patchy provision when providers fail?
The ONS recently published figures for UK monthly median pay in October, putting it at £2,276. With 20 hours of childcare costing £7,000 a year on average and full-time nursery care costing an eye-watering £14,000 a year, it is simply out of many parents’ reach. It has been noted that the cost of nursery places often exceeds the amounts that a family pay on their rent or mortgage. Does the Minister agree that this situation needs to be addressed, and will she accept the need for greater reform of the sector to deliver for children, parents and providers—but particularly for children?
Labour would reform childcare and early years. We know that children who are eligible for free school meals are already five months behind their peers when they start school. We have to ensure that they do not get left behind and that all children and families get the best support, which they need so that every child has the best start in life. With this in mind, Labour has commissioned an early years review led by the respected former chief inspector of Ofsted, Sir David Bell, who will be supported by a panel of independent experts. This review will consider how to deliver new places and have a motivated, well-trained workforce to deliver high and rising standards, and more accessible childcare, under Labour.
My noble friends Lady Goudie and Lord Brooke both highlighted the importance of good food in children’s development and learning. The health elements of this are crucial and, given that my noble friend Lord Brooke recently asked the Minister about school food, I hope that she is able to respond to his questions today.
This debate is focused on children, not necessarily on women’s ability to be economically active. However, it would seem inappropriate to discuss childcare and early years education without touching on this. Women are still largely the parents who have to put their careers on hold to have a family. This issue is particularly acute for those taking on shift work with irregular hours, such as police officers, firefighters and nurses, as well as people working in the hospitality sector. In the case of emergency responders, if they are in the middle of responding to an incident, they may end up having to work additional hours on a shift with no notice. Sites such as Mumsnet have many questions about this, but few solutions are offered other than family care or a costly live-in au pair or nanny, which is out of reach for most.
As a Deputy Mayor for Fire in London, I have spoken to firefighters who are in relationships with other firefighters or emergency responders. They work different shift patterns to care for their children, thereby rarely coinciding with their partner. This is far from ideal. We need working parents to be able to juggle work and their home life. Can the Minister say what  more the Government will do to support the early years sector to ensure that it can cater for parents undertaking shift work?
I look forward to hearing the Minister’s response to the many questions posed in what has been a hugely interesting and broad-ranging debate. I end by quoting my noble friend Lady Andrews in stressing this: “Children are invisible and their value is commodified into the cost of places, rather than optimising the benefits to them”. That is the situation we appear to be in. Childcare should not be just about providing care while the parents work, even though that is important. It should be viewed as a vital step in a child’s development. Labour will work to provide higher standards for early years provision, alongside better availability and a model that works for providers.

Baroness Barran: My Lords, on behalf of these Benches, I express my sadness at the untimely death of Lord Darling. We can have some small insight into the extraordinary pressure that he must have worked under, at a time of global financial crisis, and the calmness and judgment he brought to his role. We send our very best wishes to his family, in particular.
We have heard some powerful messages from across the Chamber today on the importance of high-quality early years education. I thank the noble Baroness, Lady Andrews, very much for securing this debate and all noble Lords who have contributed to the topic. Whatever our perspectives, today’s debate has highlighted how crucial it is that we ensure all children have the best start in life. Decades of evidence, as we heard today, has shown that quality early years education has a critical positive effect on children’s outcomes, in the short and the long term. That is why the Government are committed to ensuring that every child receives high-quality education and care.
I absolutely accept that His Majesty’s Opposition are rightly there to challenge the Government’s record but, before I talk more about the Government’s policies in this area and attempt to address some of the questions raised by noble Lords, I feel it is important for the record to say that some of the remarks about how unsuccessful our education system is are very far from the truth. We have seen a significant improvement in reading and in maths. Our children aged nine and 10 are now fourth in the world and the best in the western world at reading. There has been a significant improvement in maths as well. That has been thanks to the absolute focus that this Government, and in particular my former ministerial colleague Minister Gibb, paid to this very important plank for future education. I absolutely accept the challenges posed by noble Lords, but we need to keep the record straight on the Government’s record on education.
The noble Lord, Lord Brooke of Alverthorpe, gently again raised the important issues of childhood obesity. I will take back his thoughts to my ministerial colleagues about the importance of a review and the work he is leading in relation to ultra-processed foods. The early years foundation stage framework requires that, where  children are provided with meals, snacks or drinks in an early years setting, they need to be healthy and nutritious. We have example menus for early years settings in England and provide guidance to staff on menu planning. I hope that he takes some reassurance from the focus within early years, although I accept his concerns about the wider issues of obesity.
The quality of our early years provision was raised by the noble Baroness, Lady Andrews, and others. England has some of the highest-quality provision in the world, with 96% of early years settings rated good or outstanding by Ofsted as of August 2023, which is up from 74% in 2012. The early years foundation stage statutory framework sets the standards that all early years providers must follow to ensure that children have the skills and knowledge they need to thrive. In 2021, this Government reformed the early years framework more broadly to improve early years outcomes for all children, particularly disadvantaged children—noble Lords rightly raised the subject—in the critical areas that build the foundations for later success, such as mathematics, language development and literacy and, importantly, in play, as the noble Lord, Lord Storey, articulated so clearly.
I am delighted to be able to tell the noble Baroness, Lady Bennett, that we are making great progress in encouraging children to connect with nature. We recently launched our National Education Nature Park; I can send her the link. This is providing children in every school the chance to map their school grounds and upload those digitally, so that we can build a whole digital map. There are grants for schools with very low levels of biodiversity to be able to increase biodiversity. I visited an extremely urban school in Birmingham earlier this week to see what it was doing in relation to the nature park. It is growing vegetables; it has chickens and takes the eggs from them for the breakfast club’s scrambled eggs. I know that she is not pleased with everything the Government do, but I hope that she will accept that this is a step in the right direction.

Baroness Bennett of Manor Castle: I do not necessarily expect an immediate answer, but can the Minister perhaps think about whether it is possible to extend such a programme to nursery settings?

Baroness Barran: It has already been extended to the nursery sector. We are way ahead. But this is an important point because it sets children off in the way we hope they will continue: with a love of nature but also a sense of agency within it.
I turn to concerns that noble Lords raised about the impact of Covid on children’s development. The 2022-23 early years foundation stage profile results, published by the department today, show that there has been an increase in the proportion of five year-olds achieving a good level of development compared to last year. In 2022-23, 67.2% of children had a good level of development, and 65.6% were at the expected level across all 17 early learning goals—that is up 2% on last year. The noble Baroness, Lady Andrews, rightly raised concerns about recovery post Covid.
I thank the noble Baroness, Lady Kidron, for raising important issues about children and screen time. If the noble Baroness has time, I would be happy to meet her and talk about the additional security that we think  the Keeping Children Safe in Education guidance provides to children in education settings, although she is clearly not convinced it is achieving that. I do not think there is any difference in our aims and aspirations for the safety of children, so it would be helpful if the noble Baroness would agree to explore that in more detail. I absolutely agree with her about the importance of the privacy of children’s data.
I turn to the expansion in provision. We are determined to support as many families as possible with access to high-quality and affordable childcare. A number of noble Lords remarked on a focus on encouraging people—principally women—back into the workplace, which is an important goal for all the reasons that the House will be aware of. However, it is in no way a compromise on the quality and richness and developmental value that the noble Baroness opposite set out so clearly in her remarks.
By 2027-28, we expect to be spending in excess of £8 billion each year on free childcare. The noble Baroness, Lady Twycross, cited the current costs of childcare, which make the case eloquently for the changes that we are bringing in, because we understand that they are a tremendous pressure on those who have very young children and wish to go out to work. This huge expansion means that millions of children will benefit from the extraordinary efforts of the sector to give children the safest and highest-quality early education and childcare. As a first stage in growing and supporting the early years workforce to deliver these entitlements, the Government consulted on a number of further flexibilities to the early years foundation stage this year, which will be implemented from January 2024, so that providers can use their existing workforce better while protecting quality and safety.
The noble Baroness, Lady Andrews, asked why the Government did not consult on the planned expansion. The Spring Budget announcement responded to the concerns aired and raised by parents about the cost of childcare. Since then, the noble Baroness will be aware that we have consulted on key factors of the rollout, including funding and other changes.
The quality of our early years and childcare sector is a testament to the ongoing dedication and hard work of those in the profession. Since the pandemic, the Government have committed up to £180 million of support to promote quality and best practice and provide staff with opportunities for career progression, as we heard from a number of speakers this evening. This includes a package of training, qualifications and guidance for the workforce. We have expanded the early years professional development programme to enable up to 10,000 more level 3 qualified early years practitioners to access the latest teaching in communication and language, early mathematics and personal, social and emotional development. We are also funding the national professional qualification in early years leadership, which is designed to support early years leaders to develop expertise in leading high-quality education and care, as well as effective staff and organisational management.
In addition, we are proud to say that over two-thirds of primary schools have benefited from our investment in the Nuffield early language intervention, improving the speech and language skills of over 160,000 children  in reception classes so far. More than 500,000 primary school children have been screened to identify those with language development difficulties, which we know can be such a blocker for their future education.
The noble Baroness, Lady Andrews, asked whether the department had made an estimate of the dead weight in our expansion. There will be a full evaluation of the rollout, which will also look at that issue.
To return to the workforce issues, which were raised again by the noble Baronesses, Lady Andrews and Lady Twycross, and other noble Lords, to support providers to recruit the staff they need to deliver the expansion in childcare entitlements announced at the Spring Budget, we are developing a range of new workforce initiatives, including the launch of a national recruitment campaign, planned for the beginning of 2024, to boost interest in the sector and support the recruitment of talented staff. We are removing barriers to entering the workforce by ensuring that qualifications are suitable and easy to understand. This includes launching a competition to find providers of early years skills boot camps, which will include a pathway to an accelerated level 3 early years apprenticeship. We are also developing new degree apprenticeship routes so that everyone, from junior staff to senior leaders, can easily move into a career in the sector.
The noble Baronesses, Lady Andrews and Lady Goudie, challenged on whether the change in the staff-to-child ratio would make it harder to retain staff. As the House knows, we are providing flexibility to providers to move from a 4:1 to a 5:1 ratio, in line with that which exists in Scotland. However, ultimately, it is the managers of settings who know what support their children need, and they will know their staff best. The Government trust their judgment as to what ratios they believe are right for them in their settings. Supporting the workforce is obviously a priority, which is why we provided £204 million of additional funding to local authorities, so that providers can recruit and retain the staff that they need.
The noble Baroness, Lady Twycross, raised a very troubling case, if I understood rightly, of a child on the autism spectrum who was suspended from nursery school, which slightly defies one’s imagination. We do recognise that quality early years education means meeting the needs of all children, which of course critically includes those with special educational needs and disabilities. The House knows very well the importance of those needs being identified as early as possible, as emphasised in the SEND and Alternative Provision Improvement Plan, which we published in March this year.
We are funding the training of up to 7,000 early years special educational needs co-ordinators, and there is also SEND-focused content in the package of support and guidance for the workforce which I outlined earlier. We are also reviewing the operation of SEND inclusion funds within the current early years funding system to ensure that funding arrangements are both appropriate and really well-targeted to improve outcomes for preschool children with special educational needs.
To finish, I want to touch on an important point that was raised in the Motion of the noble Baroness, Lady Andrews, today; that quality early years education is provided not only in nurseries, childminder settings  and schools but also, of course, at home. We know that a stable and stimulating home learning environment is also crucial to children’s development. That is why we secured £28.7 million between now and 2025 for local authorities to support specifically the speech and language of young children who were worst affected by the pandemic, namely today’s three and four year-olds. That programme is being delivered through family hubs and the Start for Life programme. The noble Lord, Lord Storey, raised the importance of parenting and children having a routine, which clearly family hubs are part of delivering.
The noble Baroness, Lady Goudie, mentioned the return of Sure Start. As I think she will be aware, we believe that our family hubs really build on the learnings from Sure Start and from children’s centres and are a single place where a family can access all the support they need, including support for mothers with mental health issues, which noble Lords also raised.
Finally, the noble Baroness, Lady Andrews, invited me to meet the Early Education and Childcare Coalition and the Early Years Alliance. She may be aware that the department meets both groups very regularly and I know that the Minister for Children and Families has also met them. I would be delighted to as well, if the noble Baroness would find it useful. She also asked whether we hold data on children whose families are in receipt of universal credit. That is held by the Department for Work and Pensions, but I am happy to write if that data is available. I close by thanking your Lordships—

Lord Storey: Before the Minister sits down, I raised the issue of a new target for the 60,000 vulnerable babies and asked what the Government are planning to do on that. Will she write to me about it, as it is an NHS matter?

Baroness Barran: I would be delighted to write about that and all the other issues that I have not had time to cover this evening.
I close by thanking your Lordships for their thoughtful contributions to the debate today and to underline our shared gratitude to early years professionals who are doing such a fantastic job to deliver high-quality education to our youngest children.

Baroness Andrews: My Lords, I think that is an excellent note on which to end a very good, passionate,  as usual, and expert, as usual, debate. I thank the noble Baroness for associating herself and her party with our grief at the death of Lord Darling.
It has been a debate about quality, and lots of elements that constitute quality have been raised. Lots of questions have been asked and I am particularly grateful to the noble Baroness, Lady Kidron, for these known harms—and probably unknown harms as well. They are very important to explore. A whole range of issues constitute quality, including the value and the content of food and the absolute necessity of play—to quote Schiller, we are not fully human unless we know how to play.
I thank noble Lords for their emphasis on the essential nature of child development. Many questions were answered by the Minister but quite a few were not, so I would appreciate answers particularly to the questions I raised on the £400 million. I also have some questions arising from her winding up. There are reasons to be cheerful and we should not diminish the importance of, for example, those statistics about numeracy and literacy in the later primary years. However, while the information brought forward yesterday by the department suggested that 67% of children are in good development, there are still a third of children who apparently are not—that is a very high proportion. I would like that to be explored.
I would also like to know more about when the evaluations will start—I hope that it will be immediately. There are lots of initiatives, but the Minister did not really answer the questions which are so fundamental about the coherence of strategies, particularly for retention, and going forward with this acknowledged frailty in the system.
I have much more I could say, which I do not think anybody would be grateful to hear at this stage, but I am very grateful to the Minister because I know we share a huge range of values and both sides of the House want this policy to succeed. I am grateful that we have had an opportunity to dive a bit deeper into some of the issues. I would like to follow up some of the questions when I read Hansard and I will pass on the invitation to the agencies. I am sure they would appreciate a personal conversation with the Minister, because there are always more questions and there is always more to do.
Motion agreed.
House adjourned at 5.41 pm.